phil 339

df. triage

a means for determining the allocation of health care under conditions of scarcity; or, rationing health care by some means of prioritization

rule utiltaritanism

a right action is one that conforms to a rule that, if followed consistently, would create for everyone involved the most beneficial balance of good over bad/max utility. I.e.- doctors should not intentionally kill their patients because it most likely will provide the most amount of net happiness

rights theory

a right is an entitlement, a guarantee that one can chose to do something (regardless of the consequences); or can chose not to- it's up to them.

Moral community def

all those due moral consideration

Replenishment argument:

allow donation/sales of body parts able to be regrown/replenished (hair, plasma) but not other organs Is body=self? What is essential to personhood?

Slogan form for compensatory justice:

'No right without a remedy"- in social context, rights violations require compensation or in a practice rights don't exist. In principle, you have the rights even if they are not being held in practice.

Metaethics and free will`

'Ought implies can (and can avoid)' principle, aka principle of alternative possibilities (PAP)- moral responsibility requires both autonomy and agency (being capable of the exercise of free will)/LFW (free will)

ethics of care

(Vs. multiculturalism- we can learn from other cultures, but can also critique them when fail to fulfill roles- assumes ethical realism) Ethics of caring versus ethics of justice, stressing personal relationships and empathy/ sympathy over impersonal justice Similar to virtue ethics- morality as understood in terms of proper functioning in interpersonal roles Example of clitoridectomy (cut off young girls' clits-shows a lack of care towards the young women) and fallacy of ethical relativism- idea that we cannon critique another culture

Arras: for "interpandemic flu"

(routine flu b/t pandemics), CDC gives priority to most vulnerable (young and old); but for pandemic flu, it's counterproductive to prioritize most vulnerable because they require care by others. The social support system would collapse Worry: what if vaccines are untested/ unproven? Would we force people to be guinea pigs or only use volunteers? Pandemic quarantine- how to asses risk of vaccine vs. disease?

Ethical egoism

): always act selfishly; i.e., one ought always to act selfishly (=? In ones own long term, enlightened self-interest)- the best consequences for oneself long-term (or best intentions towards selfishness, versus actual consequences)? This is a bad theory

erin & harris

- agree with freedom to sell organs, but not to buy! Details- Confine markets to discrete political units (no international markets- smuggling/crime/regulation); Also, require central govt agency to procure all organs, So no true FM, free to sell, but not to obtain Govt to prioritize according to medical need rather than wealth. Too restrictive/ will lead to black market?

modern virtue ethics

- agrees cultivation of virtues needed for human flourishing and a good life; motivates, feelings, intensions, and moral wisdom all count

rescue principle' or 'rule of rescue'

- always attempt to ration HC on basis of need, and life-saving is always highest need (continuing quantity trumps quality).

Deontological theory

- asserts that the rightness of actions is determined partly or entirely by their intrinsic value; one must do ones duty, regardless of consequences

Legal (vs. moral) rights

- liberties/rights entitled by law; laws are duties imposed on people, and so loss of freedom/rights for others. We have legal positive rights in a hospital, but not in a doctor's office. This may not be the case for moral rights (what we ought to have)

counter argument to Radcliffe-richards

: sometimes giving ppl more choices actually does make them worse off, if they would've preferred not to have the choice- cf. euthanasia and inheritance pressures Suicide by organ donation?

According to Aquinas, human nature aims at # of goods:

-preservation of human life -avoidance of harm -reproduction and care of kind -the search for truth -the nurturing of social ties

Original classic utilitarianism (Bentham) denies any basic rights exist, because utility trumps other considerations. The ends justify the means!

...

2 parts of moral community

1. Intrinsic value- valuable in itself, even if none others value it- doesn't depend on extrinsic (external) relationships for value; members are members just in virtue of being the kind of thing they are; so necessarily due moral consideration. I.e.- an agent (maybe only example). Pleasure/happiness may be other examples 2. Instrumental value- moral consideration is merely due to care or interest of intrinsic member(s), and if that interest changes, then they no longer are due moral consideration.

But- how do we determine what a virtuous person would do? E.g., benevolence may conflict with nonmaleficence concerning the fate of an organ donor and transplant recipient

1. Virtue ethics, 1st/best answer- 4fold test: in order to be virtuous, one should... find out: 1 what good at 2 whats valued 3 what's valuable 4 what one enjoys what if its not what you like to do? Then intemperate, need to change desires through reason- GET OVER IT! 2. role model test- emulate a professional role model in order to be virtuous (problem: if don't know one, or what they'll do) 3. golden mean test- everything in moderation (eg courage as midpoint bt the extremities of recklessness and cowardice

category C diseases/agents

1. could be engineered for mass dissemination in the future bc of availability 2. ease of production and dissemenation 3. potential for high morbidity and mortality rates

process of organ transplants

1. diagnosis 2. transplant team evals the patients attitude, psychological state, 3. if approved, contact the UNOS 4. and then the OPO contacts the transplant team when there is a match, 5. if the team approves, the patient is notified and preparations are made immediately for surgery 6. the donor and patient are brought to the hospital and the surgery takes place ASAP decreased donors→ organ procurement organization→ UNOS comp system→ transplant center→ candidates

CDC's category A diseases/agents, or high priority agents all considered a national security risk:

1. easily disseminated or transmitted person to person 2. high mortality rates 3. potential for panic and social disruption 4. require special action for public health preparedness ie anthrax, botulism, plague, small pox, viral hemorrhagic fevers (ebola)

Goldman- argument for medical paternalism

1. full disclosure to patients sometimes makes them sicker (depressed, ill), or leads to suboptimal treatment decision (if fooled by/ led to charlatans, quacks by honest diagnosis/prognosis) 2. 2. Full disclosure thus sometimes detrimental to patient's health/longevity 3. act of coming to a doctor means that patient's health/longevity is highest value/priority -so coming in means you value turning over autonomy to physician; patients have no right to autonomy! 4. so worsening patient's health/longevity is contrary to patients own true value orderings (whatever they might 'say'). 5. (implicit)- if HCP and patient's true values coincide on preferred treatment, then that treatment ought to be administered. C: thus, medical paternalism is justified- HCPs should decide when/how much of truth to tell to patients, and decide on their treatment.

Emanuel- Four models of physician-patient relationship

1. paternalistic- health care provider decides patient state of knowledge and treatment, based on health care providers values (cf. Hippocratic oath) 2. informative- Health care provider gives patient all relevant info (the info required for an informed consent- the diagnosis, the prognosis, the treatment options, and the side effects), and remains value-neutral: just gives treatment options and takes patient order, like a waiter 3. interpretive- Health care provider informs patient, then tries to ascertain patient values so as to correctly apply patient values. 3' if combine approaches 2 and 3, its called the contractual approach! 4. deliberative- 'best interests" meets autonomy- Health care provider informs, then reasons together with patient to find best values, perhaps tries to persuade patient to change values, but ultimately lets patient decide

determine nature of social obligation. Do CBA for deciding allocation of HC, given amount of resources available, using 2 facors: result?

1. the cost of a proposed option in relation to alternative forms of care that achieve the same goals (welfare, etc) for patient; and 2. the cost of each option in terms of opportunity cost- foregone opportunities to apply the same resources to other social goals (besides equitable access)- e.g. education, recreation, social services, etc. result: utilitarian rationing HC? QALYs?

Who decides allocation, and under what criterion? Traditional military/emergency triage- divide into 3 groups:

1. those critically ill, who will live only if treated 2. those who will live without treatment 3. terminally ill palliative criterion would change things, relieve pain of dying but increase other deaths.

Various possible rationing criteria- and would it be a duty or a right? Coercion?:

1st come, 1st served- but riots result save the worst off 1st (say, those needing organ transplantation, or otherwise critical) reciprocity- save 1st those willing to save others (say, willing to donate organs) save the most quality life yrs? QALYs (youngest healthiest 1st) save those most likely to fully recover save most socially valuable- those who contribute most to wellbeing of others and social flourishing auction/fiscal triage- market decides (avoids black market) lottery/random selection

Ethical requirements for clinical trials

3 basic principles: respect for persons, beneficence, and justice. Result: subjects must give their informed voluntary consent to participate. The study must min risks to subjects with acceptable balance of risks/benefits Subject must be selected fairly to avoid exploiting or unjustly excluding them. The subjects privacy should be protected, and the confidentiality of research data must be preserved. Before the research is conducted it must be reviewed and approved by an independent panel The usual requirement of phase III clinical trials for human experimentation would likely be foregone in a level 6 pandemic- experimental vaccines would be needed immediately, so people would be needed quickly as guinea pigs! Also, how would we decide who gets the vaccine?

doctrine of double effect

4 necessary conditions (&jointly sufficient) for moral action with both good and bad effects: 1. act good/neutral in itself 2. bad effect not the means to the good effect- mere byproduct. 3. bad effect not intended, merely foreseeable 4. proportionality: good effect >/= bad effect example: Suppose I have a headache and I seek treatment and someone gives me an idea- shotgun blast to my temple. Good effect: headache gone. Bad effect: I die. So this is immoral. On the other hand, if someone gives me an asprin. It cures my headache but may cause stomach bleeding. This is only a byproduct/ side effect (#2). The shot gun cure would violate all 4, but the asprin cure passes!

criticisms of emanuels 4 models

: in practice, inequality of knowledge/health/stress/experience/ etc... undermine patient deliberative reasoning ability, so threatens regress to stealthy paternalism, façade of deliberation... Distinction between deception (misleading) and overt lying- deception can come from mere absence of part of truth, without overt lies. Real autonomy requires whole truth/ informed consent

virtue ethics

Agent-centered, not act-centered- focus on the development of virtuous character. So all previously discussed theories are wrong! (according to virtue ethics) Aristotle: the greatest good for humans, their true goal, is eudaimonia, which means "happiness" and "lifelong flourishing" To achieve eudaimonia, human beings must fulfill the function that is natural and distinctive to them: living fully in accordance with reason

autonomy

Autonomy- a person's rational capacity for self-governance or self determination; requires agency Autonomy principle- autonomous persons should be allowed to exercise their capacity for self-determination (paternalism principle is opposed)

Goldman's refutation:

Autonomy/self-determination is greater value than health, even when go to doctor- step 3 is untrue! Autonomy both good in itself, and required for other goods/rights- hence most important right. Replace with contractual model- autonomy/informed consent required on both side for valid contract.

please dont tell story

Carlos is in a gang and a part of a catholic family. Do health care providers have obligation to inform Consuela (Carlos' sister), who has agreed to treat brother Carlos' wounds at home, that he is HIV- positive (and gay), despite request from patient not to? Duty of patient confidentiality vs nonmaleficence/ duty to warn vs best intrests of patient? Conflict of duties, roles and related 3rd party issues...

CDC's category B diseases/agents,

Category B diseases/agents 1. moderately easy to disseminate 2. have moderate morbidity rates and low mortality rates 3. require enhanced diagnostic capabilities and disease surveillance

according to commission, do we have a right to health care?

Commission says no... instead, society has moral obligation/duty, without thereby granting an individual a right. So, nation has a duty to provide, but individual citizens have no legal right to HC (thus, no compensation/ remedy!)

best of emanuels 4 models

Deliberate is best- proper role of HCP is 'moral guide' to assist virtuous deliberation, but not force HCP's preferred conclusion about treatment

Derivative rights

Derivative rights- are ones merely instrumental towards realizing basic rights/limited in setting/scope, and hence contingent, subject to revision.

distributive justice

Distributive justice- issues of how the benefits and burdens of social life are to be distributed, but... Burdens: what are (un-)acceptable? Re 'adequacy' above- cannot impose burdens that undermine guarantee of adequate health care- cannot be so expensive so as to deprive of food and shelter, etc.

duties and rights

Duty- obligation to be moral Right- the choice/ liberty. We are permitted to do the action but we don't have to. It's everyone's duty to not interfere with others' rights. Duty to life/ right to life. Rights-holder has a choice, not an obligation. But rights do entail duties- for all others!

hippocratic oath

Embodies paternalism towards patients, understood as a covenant (only way to break is to withdraw the promise), not a contract, so an unconditional promise: To respect Gk gods, no med school fees, have only males- no women; also, no surgery, no abortions, no active euthanasia, no (gay/straight) sex w patients, keep HCP- patient confidentiality, and a curse on any who breaks the oath/covenant- and: First, do not harm (or injustice).

metaethical principles

Equality- treat equals equally; un= treatment demands a relevant disparity in persons/cases Universality- moral reasons apply to everyone, in every culture; and moral community includes everyone (but all persons/rational agents, or all humans, or all sentient beings, or all life?) Impartiality- one should not be more partial to one member of the moral community than another (without a morally relevant reason) Reasonableness- morality involves reasoning, and give reasonable advice, re PAP

What is a moral theory?

Explains what makes an action right/ wrong, or what makes a person good/virtuous or evil/viceful;

fiscal triage

Fiscal triage- criterion of ability to pay (not same as willingness to pay- can only pay what one has (or can borrow) in terms of resources). So slogan of fiscal triage- 1st treat those who can pay all, then some, then none Private hospitals/practices exhibit such fiscal triage, result is public hospitals practice ER triage... woman dies of perforated bowel in LA.

2 responses to the please dont tell story

Fleck- not imminent threat/ only a small risk, and fear of consequences for carlos if gay/ HIV status revealed to homophobic catholic family; so must maintain patient confidentiality Angell- no, Carlos must tell Consuela, or else not tell her but do without her nursing care. Any HCP, or person acting as HCP, has right to all safety-related information relating to patient care. This is a bad argument because Carlos already said he wasn't going to tell her. HCP would have a positive obligation to tell her because he probably won't and say he will. This view dances around the issue.

bone marrow transplants (london)

From 1991-4 christine deMeurers, fought against her MCO (health net) and terminal stage (4) breast cancer, standard therapies approved and failed Doctor offers new chemo called HDC/ABMT, use already harvested stem cells to autologously transplant/recreate own bone marrow after 10X normal dose chemo. Unknown if works on solid tumors like christines; now it seems the answer is no (2001). Health net refuses payment, need to raise $100k to pay... UCLA ends up absorbing costs (cf. clinical trial); four disease-free months follow, but then recurs and a yr later died. Now admits- probably would've lived longer without the treatment, efficacy still unproven

Ross, 'Disclosing misattributed paternity' article

Genetic testing, tell husband not real father and result for fetus/child?- est 10-15% occurrence... Genetic counseling: 'client autonomy' and 'don't disrupt families' as primary principles? Possible affected parties/clients: mother, husband/ biological father, fetus/future child?

principlism

HCPs have 4 prima facie basic duties: 1. Autonomy- respecting free will of patient and their version of good life/preferred treatment; 2. Beneficence- max happiness, serve interest of patient and others; 3. Nonmaleficence- do not harm patient/others; 4. Justice- distribute burdens/benefits equitably, fairness in procedures. (some include utility as 5th principle)

HIPPA and privacy privacy rule

HIPPA and privacy is the Privacy Rule that took effect on April 14, 2003. It regulates use and disclosure of info held by covered entities ( e.g., employer sponsored health plans, health insurers, and medical service providers that engage in certain transactions.) It establishes regulations for the use and disclosure of Protected Health Information (PHI).

Presidential commission on ethics of access to health care

Importance (main purposes) of HC: 1. well-being/ welfare 2. opportunity 3. information (about health) 4. interpersonal significance of illness, birth, death

katz

Katz- law based on cases about experimental treatments- dye injected to locate blockage causes paralysis, cobalt instead of x-ray radiation after mastectomy; Law now requires informed consent- defined as full disclosure of diagnosis, prognosis, alt treatments, and side effects Negligence standard- has doctor met his informational responsibility? Problems with full disclosure- role of faith in cures, HCP as like god/priests, who shouldn't acknowledge the uncertainties and possible problems with treatment, because merely being treated often has healing effects, even if therapeutic agent is (physically) useless (placebo effect)

...

Last chance therapies and managed care, daniels and sabin: coverage for unproven, last-chance? As seen in deMeurers case, ABMT refused by MCOs as unproven; gatekeeper not FDA (re trials), but MCOs.

Contractarianism

Moral or political theories based on the idea of a social contract among individuals for mutual advantage over state of nature

Deontology: duties and rights

Negative and positive rights- negative rights merely require others to avoid interfering with us, whereas positive rights require others to assist us (if desired) to secure our claims

Arras- dr. Kramer-mr. williams case:

Newlywed with high bp; antihypertensive diuretic (hydrochorodthiazide), may cause impotence- tell him, a newlywed? Possible hawthorne effect- nocebo? Informed consent- info about risks/benefits of treatment options (and so about diagnosis/prognosis/alternative treatments/side effects)- is it a positive right of patients?

Rawls- a theory of justice-justice as fairness

Original position (state of mind) & veil of ignorance- Personal Identity mixer- what rules would be just for everyone? What rules would we vote for if we could be turned into anyone

Norman daniels- rawlsian (/virtue ethics) arg for universal health care

P1: sickness and disability (S&D) prevent us from functioning properly/normally P2: S&D deprive us of equal opportunity for social goods P3: we usually have no control over becoming S&D- not culpable/not our fault P4: thus, S&D are at unjust social disadvantage P5: hence to realize ELP & DP, all S&D must have access to health care to restore proper function C: universal HC is morally mandated (regardless of ability to pay) Implication: single-payer, or other system? Whatever would maximin...

paternalism

Paternalism- the overriding of a person's actions or decision making for his/her own good- when one is not the best judge of one's own life. Weak paternalism- paternalism directed at persons who cannot act autonomously or whose autonomy is greatly diminished Strong paternalism- the overriding of a persons actions or choices even though he or she is substantially autonomous

How to rank order rights, when scope causes conflict of rights? E.g., property vs. health care vs. life vs. speech?

Perhaps- rank order by those needed for moral principles such as autonomy, respect, and dignity of persons... so rank order rights by rank ordering the values they represent.

problems with triage

Problems: population-centered concerns- imprudent use of shared resources ('stewardship') and promotion of public goods, re knowledge gained through clinical trials. Must meet established net benefit, paid for in clinical trials Vs. Patient-centered concerns- urgent needs in last-chance situations, avoiding harm (incl psychological), managing uncertainty/risk. Would emphasize a lower standard of evidence for permissible last-chance treatments, give doctors and patients more leeway in calculating costs/benefits.

The Health Insurance Portability and Accountability Act (HIPPA)

Title I of HIPPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. It helps people keep their information private.

responses to Ross, 'Disclosing misattributed paternity' article

Usual institute of medicine recommendation: 1 disclosure to mother alone, re: "don't disrupt families' alternatives: 2 to neither parent (just report test result- 'don't ask, don't tell?); or 3 to both parents, including husband, but not father? Ross recommendation: 1983 govt report is correct, last is best (tell both parents, but not biological father)

virtue ethicists claim...

Virtue ethicists claim that acting merely out of a sense of duty (cf. Kant) is not the ideal morality, but a barren approach to living a virtuous life- one needs inclination and duty to coincide for perfect virtue, rather than mere continence

WHO and pandemic levels

WHO and pandemic levels 1-6; 2009- officially a pandemic: level 5 swine flu Swine flu (H1N1) is easily transmissible, but so far not very lethal Avian flu (H5N1) not currently person to person transmissible, or else already had level 6 pandemic

virtue

a character trait or disposition (revealed by habit) that leads to excellence/flourishing (excellent attainment of goal, playing role)- leads to good habits, involves proper functioning within a role

sabin/daniels

answer is to design procedures that are 'just enough'; procedural solutions such as outside review panels and internal appeals

converse correlativity theorys

any ascription of duties for oneself involves corresponding right(s) for some other person(s)- blatantly false bc all rich ppl need to give to charity but charity is NOT entitled to your money. Also, 4 way stop: if all 4 stop at the same time, no one has the right to enter the intersection 1st. everyone has a duty, but not the rights. Someone will go anyways even though not entitled.

correlativety theory

any ascription of rights for oneself involves corresponding obligations for all other persons

dwyer: HC for illegal immigrants

args: 1. legal prescence means denial of public benefits? But why should breaking a law guarantee no health care? We give health care in prisons, mental assylums, etc- ASH, men's colony 2. why give better treatment to illegal's than own citizens- no right to HC? Given scarce resources, why not make legal residence criterion for rationing? 3. Professional ethics- duty to treat? In ER, vs private practice? Do we use only medical need as basis for rationing/ triage? Cf 'ability/ willingness to pay' and financial triage. Cant have paramedics/ ER asking for passport b4 they begin treatment? 4. human rights- do we all have a basic positive right to HC? US govt says no, but new HC bill changes? 5. social responsibility- illegal's still are members of socirty (or should become?) and hence responsibility to them...? Consequentialist argument against- guaranteeing HC to all will only encourage illegal immigration.

Radcliffe-richards

argument for selling- prohibition leads to "pareto inferior"- leaves both potential organ donors and recipients worse off. Recipients lose life, donors profit; if allow sales, win-win! (Cf. Rawlsian DP) Poor/vulnerable exploited? No, would only sell if best option available, and if so, then the rest of social life exploits even worse. How does preventing them taking best option available advance their interests? Would allow international market (re Chinese)- prisons, etc as harvest? So R-R suggest free market should be allowed- both donors and recipients allowed to buy/sell organs, denying either leads to pareto inferior outcome

ethical naturalism

asserts that one can go from an 'is' to an 'ought' by using human nature.

Consequentialist theory

asserts that the rightness of actions depends solely on their consequences

vice

disposition that detracts from flourishing/ excellence in one's proper role- leads to a bad habit

Kant's categorical imperative (CI), versions 1 and 2

cI1: "act only on that maxim through which you can at the same time will that it should become a universal law."- if you enslave enslave someone it is immoral bc if you enslaved everyone in the world, who would be the slave owners? So this is immoral. Or, if I want to make someone feel good about themselves by lying to them, this would be immoral because you can't universalize lying. Liars paradox. Are these statements truth or lie? "this statement is a lie." And "I have universalized lying." They aren't either/ they are both? cI2: "always treat all persons, whether oneself or another, as an end in themselves, and never as a mere means." Only applies to rational beings. Has to do with respect and dignity? To be moral we can't do anything that substantially affects another person without their consent.

Aristotle:

cardinal rule of the golden mean and 'moderation in all things' Means-end relationship, subordinate (instrumental)/final (intrinsic) goals- sole shared final goal, eudaimonia

mixed theory

duties and intended/foreseeable consequences both matter; Aquinas, conscience and radio analogy

equal liberty principle

each person participating in a practice, or affected by it, has an equal right to the most extensive liberty compatible with a like liberty for all

what should we morally do in rationing vaccines in a pandemic? Emanuel and Wertheimer:

ethics required the moral equality of each member of society. This leads to the ... life cycle approach (each person should have an equal opportunity to live through each stage of life) but revised- investment revision: give priority to those who have already made a substantial investment in their lives. So priority to younger full persons: 1. highest priority is 1st responders (&vaccine manufacturers) 2. those ages 13-40 (with less than 2 risk conditions) 3. those 7-12 and 41-50 4. 6 months-6 yrs, and 51-64 5. over 65 or critically ill

wrong act

forbidden, moral obligation to avoid- ought not do; "right act"=obligatory, ought to do

what is equitable access? equality of access, access to whatever an individual need (or would benefit from), access to an adequate level of care? def of having access to an adequate level of care

goal is equitable access: understood as 1. equality of access- too great an interference with liberty, use of resources for frivolous purposes; would create a black market of health care for the wealthy 2. as access to whatever an individual needs (or would benefit from)- problem of definition: need not same as wants/benefits; need= especially important benefits? (re therapy/ enhancement?). so need collapses into access based on benefits;= 'whatever a person wants?'; or could be interpreted minimally, need= 'only that necessary to prevent death...' 3. as access to an adequate level of care?- BEST DEF!- everyone should have access to enough care to achieve sufficient welfare, opportunity, information (about health), and interpersonal concern to facilitate a reasonably full and satisfying life.

US govt thinks we should ration vaccines by,,,

guiding principle is the same as emergency triage- save the most lives National vaccine advisory committee (NVAC) and the ACIP recommendations for prioritization of pandemic influenza vaccine: Tier 1A healthcare workers Health care workers with direct patient contact and critical health care support staff Vaccine and antiviral manufacturing personnel Tier 1B highest risk groups Patients 65+ with high risk conditions Patients 6 months-64 yrs w/ at least 2 high risk conditions Patients hospitalized w/in past yr due to pneumonia, flu, or other high risk conditions Tier 1C household contacts and pregnant Household contacts of children under 6 months and severely immunocompromised individual Pregnant women Tier 1D pandemic responders Key government leaders and critical pandemic public health responders Tier 2A Patients 65+ with no high risk conditions Patients 6 months to 64 yrs with one high-risk condition Children 6 months- 23 months Tier 2B critical infrastructure groups Other public health emergency responders, public safety workers, utility workers, critical transport and telecommunications workers Tier 3 Other key government health care decision makers Individuals providing mortuary services Tier 4 Healthy patients 2-64 yrs without any high risk conditions

counter argument for ethical egoism

has both wrong size and incoherent membership for intrinsic moral community- EE says always 1- myself- but that changes person to person, whereas it seems intrinsic members of moral community Only change when go out of existence, not on which person is doing moral evaluation!

difference principle

inequalities (in the burdens/benefits of various practives (with offices/positions)) are arbitrary/ unjust unless it is reasonable to expect that they will work out to make the least- advantaged better off (maximin), given equal opportunity and gained by merit

phi

is any information held by a covered entity, which concerns health status, provision of health care, or payment for health care that can be linked to an individual. This includes any part of an individual's medical record or payment history. Covered entities must disclose PHI to the individual within 30 days upon request. They also must disclose PHI when required to do so by law, such as reporting suspected child abuse to state child welfare agencies. A covered entity may disclose PHI to facilitate treatment, payment, or health care operations or the covered entity has obtained authorization form the individual. Or for short list of other reasons the most prominent serious threat to health or safety. However, when covered entity discloses any PHI, it must make a reasonable effort to disclose only the minimum necessary information required to achieve its purpose. Privacy rule requires covered entitites to notify indivduals of uses of their PHI, and keep track of disclosures of PHI. Covered entities must appoint a Privacy Official and a contact person; patient can file complaint with the HHS Office for Civil Rights (OCR). However, the OCR has a long backlog and ignores most complaints. Over initial 4 year period, 23,896 complaints related to medical-privacy rules, but not enforcement actions against hospitals, doctors, insures or anyone else. Three-quarters of the complaints closed, typically because no violation found or after informal guidance to the parties involved.

Cantor and Baum conclusion

is that so all HCPs, including pharmacists, have compassionate duty of care. If you want to refuse, must either serve a community with same morals or if not give notice and referral. Facts about RU 486 vs. plan B is a different drug, but smaller doses ( 10 to 200 mg) of RU 486 can be used as an attempt to prevent ovulation and/or implantation. Higher doses (600 mg) are now being used for early abortions (up to 7 weeks).

hobbes

legal/moral positivism, social contract, only necessary value is survival. We cant survive in the state of nature for long.

nozick

libertarianism, "entitlement theory": only 2 negative rights exist, liberty and property; justice is procedural, nonconsequentialist, with minimal 'night watchman' state. We should all have negative rights, but not positive rights

Distinction between "statistical victims" and "identifiable victims"

money spent on prevention (e.g., anti-smoking campaigns) statistically saves more lives than 'last chance therapies'

permissible act

neither obligatory nor forbidden. Morally acceptable to do, or not to do; divisible into... 1. Supererogatory act- good but not morally required- altruistic, beyond call of duty; permissible to avoid, but better if done ie giving to charity 2. infraerogatory act- morally permissible but below ideal morality- permissible, but better if not done. ie sleeping in instead of going to class

slogan

no rights without responsibly- only those capable of agency/autonomy can meaningfully have rights; so no animal rights? No new born baby/fetus rights?- so mistreat as wish, have mere instrumental value? NO- because converse doesn't hold.

Joralemon and Cox

no, kantian- ought not to treat persons as commodities, but as intrinsically valuable, ends in themselves; allowing sales commodities both organs and persons donating them, treats self as mere means Even compares not viewed as mere market resource, but enduring value as physical remnant of person, and intimate relation body-person explains burial rituals, etc. Also, distinguish what desperate poor person could rationalize, vs what social institutions should normalize- allowing organ sales treats poor w/o dignity/respect, as mere commondities for rich But: why allow organ donations then?

greatest happiness principle

one ought always to act so as to create the greatest amount of net happiness (utility) for the largest number of people. This would have to be calculated, but that is difficult to do for every action, so to fix this problem, rule utilitarianism provides solution.

Cantor & Baum, Limits of conscientious objection-

pharmacists and emergency contraception. Should pharmacists have right of conscience not to dispense, versus patient right to obtain prescription? Argument for the pharmacists is the right to object. 1. Rights to independent judgment. 2. Personal integrity (not forsake morals as condition of employment). 3. (weakest) Conscientious objection is required for democracy. Argument against the pharmacist right of object is to chose to enter a profession bound by fiduciary duties and is the best interests of client. Based on your best interest and must go with what you do.

principles act as...

prima facie duties/virtues, may be overridden 'all things considered'

why do values change

principle of alternative possibilities, technology, and value change: technology changes the possible, and hence morality; values change as a result. New technologies mean new questions about what we ought (not) to do, as we can do more/have greater autonomy- i.e. ethics of human enhancement

Managed care organizations (MCOs, incl HMOs and PPOs):

rations health care amongst subscribers on daily basis; targets insured and rations based on fiscal scarcity (zero-sum), not by natural shortages or need

natural law theory

right actions are those that conform to moral standards discerned in nature through human reason

Basic rights (also called universal or intrinsic human/person) rights

rights all persons have just in virtue of being a person/human, Perhaps- basic rights are those required for autonomy?

Utility

the net consequences- cf. profit!

Critics of modern virtue ethics

the possible conflict of virtues in a particular context- no action guidance? Advice: when faced with a moral dilemma, we should do what a virtuous person would do.

act utilitarianism

the rightness of actions depends solely on the net good (happiness) produced by actual (not foreseen, intended, or foreseeable) individual actions. Intensions don't matter, only the outcome. Ex- if someone holds the door for someone, allowing them to leave a second earlier and at that moment a meteor strikes her, then the person who held the door was immoral. Also, if 5 people are dying and you could kill one person to save 5, you should kill the person

problems with determining equitable access?

uneven and unpredictable needs. Who should ensure access? Market mechanisms? Inability to pay undermines access, then;

teleology

virtue ethics is process oriented- toward a final goal or purpose (e.g., moral perfection, wisdom)

3 objections to the argument by ross

woman and child placed at physical risk, woman at psychological risk, fails to respect woman's right to privacy. The rebuttal would be that the woman created first two herself, and most men don't abuse. Rebuttal to the third point (most important) would be that truth-telling not invasion of privacy-both parents are the clients, not just woman. Should also offer to counsel child at later time. So 1983 presidential commission correct, common practice immoral. Ross is vying for the right to know.