Med Ethics PH 251 Final

Radcliffe Richards vs. others on Medical Profession Integrity argument

if the money making practice would undermine confidence in medicine then the same problem would happen in all private practice. BUT... -the emphasis isn't on the exchange of money it's the harm done for money

Autonomy

Brock

The difference between business and medicine according to Miller et al.

Business: - serves consumers - consumer sovereignty: subjective preferences and money rule - respond to consumer demand - advertise Medicine: - serves patients - patient autonomy: informed consent and the right to refuse medical treatment - doctors diagnose patients and recommend treatments; patients can only request medically appropriate treatments - advertising is still a problem

Miller, H. Brody, and Chung on the internal morality of medicine

the practice of medicine is governed by a moral framework: - goals of medicine (Hasting's Center) - role specific duties - clinical virtues Business has its own ethics and medicine has its own ethics

Miller vs. Healing

the role of the physician is not to heal all human suffering, but only that suffering connected to a malady

Emmanuel's advantages of a single-payer system

universal coverage enhanced efficiency

Miller vs. Autonomy

usually when people are informed they can make their own decisions but cosmetic surgery stigmatizes and advantages the wealthy

Wealth

virtually any legally exchangeable social asset

Applying informed consent

what about diminished autonomy of the patient? what if their life is at risk?

Preferences

what society deems attractive ex: double chins - suffering is the result of social preferences, tastes, fads and fashions for which society is not to blame

Joralomen and Cox on Hypocrisy

what would you do if your child's life depended on you selling a kidney? J and C: - the problem isn't the act (saving kid); deontological basis wouldn't justify the practice (selling kidney) -- not talking about the consequences of actions we are talking about the practice itself - if you sell yourself into slavery to save your kid that doesn't legalize slavery

Kantian, Rawls, and Utilitarian approach to healthcare

GHP and Kingdom of ends unknown whether we have a right to health - in the middle in terms of government and regulation

Norms of appearance

Little's norms of what society finds attractive

Key features of the Affordable Care Act

- Patient's Bill of Rights - everyone must be insured or pay a penalty "tax" - provides coverage for those with pre-existing conditions - extends young adult coverage to 26 yrs old - state-run insurance exchanges that provide public and private health plans

Outside the domain of medicine according to Miller

- capital punishment by lethal injection - anabolic steroids have nothing to do with treating/preventing disease involve harms that aren't outweighed by benefits physicians misrepresent practice of medicine

Himmelstein and Woolhandler's fiscal arguments

- lower bureaucratic/administrative costs - one payer, one form, one negotiated fee schedule instead of different insurers with their own rules and paperwork - low overhead - eliminate/reduce the cost of: advertising/marketing, explaining coverage, determine patient eligibility, billing, collecting

Criticisms and Responses to letting people refuse medical treatment during transplant

- lower rate of success: yeah but most people care about their own survival - doesn't address scarcity and efficiency: if careful screening for people who will have successful and voluntary transplant then you won't have a problem - less data which is worse for the program and future patients: has to develop in a way that respects patient autonomy

Callahan's moral argument

- physician's role is to heal not kill

Emmanuel's disadvantages of a single-payer system

-addresses only finance and not delivery -even with respect to finance, does not address fraud and eligibility (e.g. Medicaid) - with respect to delivery it doesn't address: -- fragmented delivery -- current delivery system focuses on acute care, not chronic care -- poor quality of care -- use of unproven, non beneficial, marginal, or harmful services is common - institutionalized fee-for-service, which hinders integration and coordination of care - deceptive administrative savings (wouldn't lower costs overall because of fraud and information technology) -ineffective cost-control strategies may involve: -- constraining the supply (ration technology, services, maintenance) -- low prices and fees (low prices, doctors forced to do more in less time) -- doing nothing, no real savings

Little's different norms of appearance

-preferences -prejudices -suspect norms

Himmelstein and Woolhandler's political arguments

-upgrade coverage for the poor and middle class -free choice of providers -address other problems in healthcare --- overuse of technology --- drug industry exorbitant profits --- imbalance between preventative and curative care --- poor quality of care - allow healthcare workers to focus on care not bureaucracy

National Federation vs. Sebelius Issues

1. Constitutionality of the individual mandate under Congress' Article one powers under the Commerce Clause or the Tax and Spending Clause 2. Constitutionality of the Medicaid expansion under Congress' spending powers

Human Research (not in developing countries) and Principlism

1. Respect autonomy- informed consent 2. Non-maleficence: placebo arm of research - What if participants need the drug but aren't receiving it? 3. Beneficence: need to make sure the benefits of research outweigh the harms 4. Justice: distribution of the benefits and burdens of research must be fair; can't exploit participants

Miller et al.'s role specific duties

1. competence in the technical and humanistic skills required to practice medicine 2. avoiding disproportionate harms that are not balanced by the prospect of compensating medical benefits 3. refraining from the fraudulent misrepresentation as a scientific practice and clinical art 4. fidelity (loyalty) to the therapeutic relationship with patients in need of care

National Federation vs. Sebelius Holding

1. the individual mandate wasn't a constitutional exercise of Congress' Commerce Clause Powers, but can be construed as a 'tax' and therefore a constitutional exercise of Congress' Tax Powers -- the law didn't regulate commercial activity -- the law can be fairly construed as a 'tax' on those who refuse to buy insurance 2. the Medicaid expansion was a constitutional exercise of Congress' Spending Power, except the penalty of taking away existing Medicaid funding

Miller et al.

AGAINST cosmetic surgery - against goals of medicine: nothing to do with treating or preventing disease, injury, or malady - conflicts with duty of physician: they involve causing or risking harms that are not compensated by the medical benefits - physicians engaged in these practices misrepresent the practice of medicine LIES IN THE PERIPHERY

Jarolemon and Cox

AGAINST market in organs focus on cadaveric donations (cadavers are part of the self not property) respond to these concerns: - commodification -hypocrisy - duty to rescue - superstition

Applying Surrogacy

Are surrogate mothers being exploited? Do we really have informed consent? Does surrogacy destroy autonomy?

Pellegrino and Callahan approach to Internal Morality of Medicine

Aristotilian and teleological - medicine has a certain scope - medicine is an art that aims at healing - healing: making a patient well, prescribing drugs to cure or maintain life and health (palliative care- keep patient comfortable) - not healing: serving my own self interest, prescribing lethal drugs to end life (PAS) -Pellegrino: Physician-patient relationship - Callahan: against PAS CONTRAST WITH MILLER ET AL.'s version in cosmetic surgery

Objections raised toward Miller

Autonomy: this is a free society Cosmetic surgery heals a kind of suffering (suffering from bad body image) reconstructive plastic surgery corrects damage caused by disease or injury

Embryonic Stem Cell Research

Do embryo's have a moral status? If so we could be killing a person. - against Kant - Util would say this is ok if it satisfies the GHP

Applying Embryonic Stem Cell Research

Do embryos have moral status? If so we could be killing a person. bad for Kant Utils say it's ok if it satisfies GHP

Radcliffe Richards et al.

FOR market in organs argue against common objections: - exploitation of poor - unequal access - integrity of the medical profession -slippery slope to selling vital organs - exploitation of the poor in other countries

Applying Gene therapy and genetic enhancement?

In favor of parental autonomy? Worries about non-maleficence but it could be said that it is beneficial when it is all purpose (immune system, memory, attention)

Pellegrino

Internal morality of medicine -observe the law of the land (laws, licensure, protect human subjects, prohibit discrimination) -observe the ethics of rights and duties (truth telling, promise keeping, non-maleficence, beneficence) -practice virtue --> perception and sensitivity to circumstances --> do the right thing even at great cost to oneself

Rawls' conception of justice and/or equality

Liberalism - not socialist because not everyone gets the same - justice as fairness - veil of ignorance, original position - negative and limited positive duties Two principles: -principle of equal liberty -principle of fair equality of opportunity whether there is a right to healthcare depends on how we weight healthcare compared to other goods more likely to have healthcare than Nozick

Nozick's conception of justice and/or equality

Libertarianism- not egalitalitarian (people don't deserve equal) -every person has a right to liberty and property (right to holdings) -- violation of property rights and justice if you have to give the government your property - a person does not owe any other positive duties -a person only owes others a negative duty not to harm Overall: no right to healthcare less regulation, smaller government

Reform proposals implemented under Affordable Care Act

Market reforms tax credits for individuals and small businesses individual mandate employer mandate expansion of medicaid American Health Benefit Exchanges NOT single payer finance

Domain of Medicine

Miller designates a zone between medicine and not medicine, the periphery, within which a procedure or practice is a matter of judgment

The Periphery

Miller thinks cosmetic surgery lies in the periphery - can address objective physical problems (stain on face) or psychological problems with the help of other professionals - cosmetic surgery should be more in line with the goals of medicine - avoid misleading and unprofessional advertising - traditional cosmetic surgery is outside the domain of medicine

Truth Telling and Principlism

Principles of respect for autonomy and nonmaleficence better to tell the truth unless it is outweighed by harm but remember not knowing could cause harm bc they may want to prepare and make final goodbyes

Principle of equal liberty

RAWLS each person is to have an equal right to the most extensive scheme of basic liberties compatible with a similar scheme of liberties for others ex: political liberty, speech, assembly, conscience and thought, personal integrity, property, freedom from arbitrary arrest

Miller vs. Reconstructive plastic surgery

RPS is not cosmetic surgery, it's a medical practice cosmetic surgery doesn't correct damage caused by disease or injury

AMA Proposals

Reforms to the current system Tax credits individual choice of health insurance new health insurance markets

Truth Telling and Kant

Respect for autonomy perfect duty not to lie must tell the truth

Rights-based approach: Does a patient have the right to refuse medical treatment despite giving consent to the transplant and agreeing to the standard restrictions?

Right to refuse medical treatment nothing specifically says they give up this right and even if it did it probably would not be enforceable balance against: - transplant program's interest in scarcity (avoid waste) - transplant team's interest in successful transplant, professional care, and obtaining data to serve other patients RULING: CAN REFUSE MEDICAL TREATMENT - only voluntary compliance with restrictions

Radcliffe Richards et al. in response to unequal access argument

That sucks- but if everything has to be equal then there are tons of other things that shouldn't exist

Socialist conception of justice and/or equality

Welfarists/ Virtue theorists Marx more regulation, bigger government negative and positive duties - duty to beneficence Overall: we have a right to healthcare

Applying IVF

What about infertile couples who can't afford this option? If it was accessible to everyone what would happen to adoption rates?

Emmanuel

against single-payer system - it has two advantages and many disadvantages

Human Research (not in developing countries) and Kant

against this - Humanity formulation- we shouldn't treat people as means

Ethical Issues with Cosmetic Surgery

autonomy vs. paternalism integrity of the medical profession imbalance between the risks and benefits harmful definitions of normal and beauty

Transplant consent forms

benefits risks you have the right to refuse medical care and change your mind at any time consent including followup treatment - does this violate a patient's right?

Hasting's Center's four goals of medicine

broader 1. prevention of disease and injury and promotion of the maintenance of health 2. the relief of pain and suffering caused by maladies 3. the care and cure of those with a malady and the care of those who cannot be cured 4. the avoidance of premature death and the pursuit of a peaceful death - PAS could be consistent with internal morality of medicine

Utilitarianism and Human Research

consider the consequences: do the consequences outweigh the burdens? research if the benefits outweigh the burdens - medical advances - helps many only hurts a few so its good

Truth telling and Utilitarianism

consider the consequences: will knowing the truth result in a better outcome? Better to do what is most beneficial and least harmful for the patient and others

managed competition (e.g. federal employees)

create managed competition program for all Americans, for example, through vouchers for families to select among competing plans (similar to federal employees program)

customary approach to screening transplant candidates

decision made based on unstated, but common considerations (e.g. chance of survival, quality of life, age, family support, drug addiction, alcoholism, etc.)

committee selection process for screening transplant candidates

decision made by ethics committees which may develop a set of rules

lottery approach to screening transplant candidates

decision made by lottery regardless of ability to pay, race, or other factors

Deontological approach: Does a patient have the right to refuse medical treatment despite giving consent to the transplant and agreeing to the standard restrictions?

decision procedure: act from the duty/ principle of respect for patient autonomy (never treat a patient merely as a means) perfect duty: respect for autonomy imperfect duties to others RULING: CAN REFUSE TREATMENT - only voluntary compliance with restrictions

Utilitarian approach: Does a patient have the right to refuse medical treatment despite giving consent to the transplant and agreeing to the standard restrictions?

decision procedure: greatest benefit for the greatest number, balancing harms and benefits - harm to one individual vs. benefit to many - benefit to transplant program (efficiency, avoiding waste, best use of scarce resources) - benefit to current donor and future donors - transplant team's benefits of achieving a successful transplant, providing care for this patient, and obtaining data to serve other patients RULING: PATIENT'S CONSENT FORFEITS RIGHT TO REFUSE MEDICAL TREATMENT

Miller et al.'s virtues

dispositions of character and conduct facilitating excellence in pursuit of the goals of medicine

Weak Paternalism

doctor can only override patient's decision when: -patient's autonomy is diminished - patient may cause harm to himself or others

Strong Paternalism

doctor does what he wants (overrides the patient's decision) whenever beyond even the two limited circumstances; broader

Nielson's view on healthcare

egalitarian (more than Rawls) we have a duty to provide free and open access to healthcare (universal basic need) - everyone deserves healthcare and to receive the same quality of treatment regardless of ability to pay Respect autonomy- need more equality because everyone matters equally (moral equality) equality of condition/ arrangements can't favor some MOST LIKELY TO GIVE HEALTHCARE- PUBLIC SYSTEM - Canada does this and US should -socialism is equally likely

Ethical and legal basis of right to refuse medical treatment

ethical: respect for patient autonomy legal: common law, liberty interest, right to privacy 14th amendment

expansion of public sector programs

expand public programs such as Medicare, Medicaid, and CHIP

new health insurance markets

expand to non-employer group markets, such as state employee health benefits system - modified community rating: risk rating and premium variation based on sex and age only - guaranteed renewability - subsidies for high-risk individuals

single-payer finance

government pays for insurance for everyone with public funds, which would provide universal coverage and high quality of care for everyone

Right

has a corresponding duty but has to have someone to accept it

Suspect Norms

how society imposes punishment for norms that are morally suspect ex: black skin or size eight, good woman -suffering is the result of extreme social punishment (not only teasing, but also fewer opportunities) for norms that are morally suspect or unjust - norms that view some group as occupying less than human status

Prejudices

how society reacts to the unusual -suffering is the result of social reactions to those who deviate from the norm, for which society bears some blame ex: pointy ears

Truth telling and confidentiality and Rule Utilitarianism

if all physicians broke confidence or didn't tell patients the truth, then the trust between physician and patient would dissolve, so we shouldn't do it

Radcliffe Richards et al. on exploitation vs. others

if there are willing vendors and recipients isn't it worse to deprive them? BUT... others may say: - vendors aren't competent to make autonomous decisions BUT... RR would say -- they should be informed -- if it's a problem of capacity then someone else should make the decision -- if no competent person can choose to sell their organs that doesn't make sense --- you can regulate the risks for the poor through regulation if they don't have good medical care not prohibition - poverty restricted them so organ selling is the best option; they don't have enough options BUT... RR would say this would lessen poverty until organ selling wouldn't be the best option anymore and nobody would want to sell

individual choice of health insurance

individuals can choose coverage (including coverage through their employers) based on their healthcare preferences and values

Transplant donor-related issues

informed consent competency exploitation compensation medical malpractice (e.g. consent, determination of death, premature retrieval)

Transplant recipient related issues

informed consent right to refuse medical treatment treatment/research right to privacy medical malpractice (e.g. misdiagnosis as best course of treatment, negligence during surgery, post-transplant treatment)

Paternalism

interference with, limitation of, or usurpation (taking someone's power or property by force) of individual autonomy justified by reasons referring exclusively to the welfare or needs of the person whose autonomy is being interfered with, limited, or usurped Callahan

Radcliffe Richards et al. on Commodification

it's not commodification of body parts compensation is for: loss of income or other lost opportunities bearing risks sacrifice

Principlism

justice beneficence non-maleficence respect for autonomy

employer mandate

legal mandate requiring employers to provide insurance or pay a fine

individual mandate

legal mandate to require adults to buy insurance for self and dependents

Different approaches to screening transplant candidates

market approach committee-selection process lottery approach customary (medical discretion) approach

Reform proposals

market reform tax credits individual mandate employer mandate expansion of public sector programs managed competition (e.g. federal employees) single-payer finance

Joralomen and Cox on Duty to Rescue

no duty to rescue a person who's organs failed no utilitarian duty to spend more resources on organ transplants rather than other transplants especially since there is a low survival rate only available to the wealthy

Joralomen and Cox on Commodification

others: risks or exploitation involved are a matter of degree not kind J and C: - just because other activities are dangerous and people do them doesn't mean they should and we at least shouldn't add more dangerous activities

Truth-telling and confidentiality and Kant

perfect duty not to lie would fail the humanity and universal law formulation

Truth Telling and confidentiality and Act Utilitarianism

permissible to break confidences in some cases if doing so would satisfy the GHP

Principlism and Human Research

principles of respect for autonomy, nonmaleficence, and justice informed consent, protection of vulnerable subjects, no unfair selection of subjects

Market approach to screening transplant candidates

provide an organ to anyone who can pay for it with private funds or insurance

Annas

recommends an approach that screens potential recipients based on exclusively medical criteria (probability of successful transplant and rehab), reviewed by an ethics committee, and open to public comment

Market Reform

reforms to private delivery, such as guaranteed insurance renewability and modified community rating (only factoring in age and gender to determine premium rates), encouraging retention, lowering administrative costs, lowering premiums

Tax credits

refundable credit subtracted from taxes owed, allowing households to buy insurance

Human Research and Kant

respect for rational agency must not kill or torture must not harm without consent

Resource Allocation Issues with Transplants

scarcity, low supply of organs equality (poverty or geographical region) efficiency rationing decisions

Degrazia's argument regarding healthcare

single-payer and private delivery system 1. universal coverage 2. keeping costs under control 3. enhancing-- or at least not diminishing-- patient choice 4. maintaining high quality of care

Himmelstein and Woolhandler's view

single-payer system - fiscal arguments -political arguments

Principle of Fair Equality and Opportunity

social and economic inequalities (distribution of wealth doesn't have to be equal) are to be arranged so that: - difference principle: inequalities work to the advantage/benefit of those that are the worst off (income and wealth are primary goods) - equal opportunity: positions and offices open to all

Little's view on cosmetic surgery

sometimes perform the operation, always fight the system - physicians should not be required to respect patient's autonomy in all cases - physicians should try to avoid doing surgeries that involve suspect norms of appearance - suffering is a psychological phenomenon

Legal approach to resource allocation

standardized medical criteria avoid waste and promote efficiency medical urgency through priority rankings review not based on geographic location