Medical Ethics Final

NCPHSBBR - the Belmont report

what does the belmont report say about human experimentation? - Treat individuals as autonomous agents (when they are) Protect individuals when their autonomy is diminished what does the belmont report say about conflicts between research and well being? - do no harm (maximize benefit, minimize harm) justice: fairness of distribution (benefit/cost) what is the belmont report's relation to tuskegee? - the belmont report was created in 1979, to ensure justice to all participants of experiments what are the 3 basic principles? - respect for persons beneficence justice -respect for persons (acknowedgement of autonomy) -beneficence (must not only refrain from harming those involved but aim to help them) -justice (involves just distribution of potential benefits and harms and fair selection of research subjects)

Fair Equality of Opportunity

the Two Principles of justice: how do we create the fairest society a.Result: The Two Principles of Justice i.First Principle: Each person is to have an equal right to the most freedom compatible with everyone else having that same amount of freedom. ii.Second Principle: any social and economic inequalities MUST be arranged so that they: (a) Are attached to positions and offices open to all ("fair equality of opportunity"). (b) work to the benefit of the least advantaged group in society. (Maximin) b.Daniels (a preview) Healthcare is a good, perhaps a primary one, but its main importance is healthcare's connection Fair Equality of Opportunity. Young invincible cases: "All messengers are uninsured. You're covered by workman's comp if your accident happens during work hours [but most don't]... They also tell you that if you get into an accident you're fired."

Herd immunity

% of a population that must be vaccinated to prevent transmission

Tuskegee Experiment: basic facts and history

1932-72 studying the natural progression of untreated syphilis in rural African-American men in Alabama under the guise of receiving free health care from the United States government.

the president's council on bioethics - the case against cloning-to-produce-children

A: ETHICS OF HUMAN EXPERIMENTATION In order to clone humans for reproduction, we'd need to experiment on human beings (donor, birthmother, and child to be). Cloning human beings would affront the spirit of the three documents governing human experimentation: the Nuremberg code, the Helsinki Declaration, and our own sweet Belmont report in the following ways: 1. Safety: current procedures threats to safety of (a) the child: few live, and those that do have fatal complications of reduced quality of life. There are serious health risks and mutations. (b) the egg donor and birth mother: super ovulation, spontaneous abortion and late-term failures of pregnancy. Even if it becomes safer, it is still experimentation involving a vulnerable population, unable to offer consent. UNETHICAL EXPERIMENTATION ON THE UNBORN. There is no ethical way to try to discover whether cloning can ever become safe, now or in the future. 2. Consent: Bringing someone into existence does not justify maiming or harming that individual. the unborn cannot give consent. 3. because women are the only source of human oocytes, and many hundred per successful experimentation are required,l research on reproductive cloning could impose disproportionate burdens on women, with low-income women being particularly vulnerable to economic coercion. B: ETHICS OF SOCIAL EXPERIMENTATION: reproductive cloning is not only a biological experiment, but also an experiment in human procreation, genetic choice and design, family and social life. born children are gifts and blessings, not a product of our wills. born children are their parent's equals in dignity and humanity, and they are unique while at the same time in a network or relation and identity, including social identity. C: PSYCHOLOGICAL AND EMOTIONAL IMPLICATIONS: what would be the psychological and emotional state of children produced by cloning? 1. problems of identity and individuality. 2. manufacture: the question is not just to have a child -- but what kind of child to have. children would be made to order by their producers. 3. a new eugenics: genetic enhancement to improve genetic constitution of one's descendants. could be dangerous to our humanity. 4. troubled family relations 5. effects on society: we need to ask what forms of bringing children into the world we want to encourage, and what relations between generations we wish to preserve. It objectifies children, viewing them as projects we can control. The precautionary principle should guide us with cloning. Cloning is unjust for the child; deprivation of natural parents, subjecting child to risks, imposition of the chromosomes of someone else. CONCLUSION: cloning is not only unsafe but morally unacceptable.

Basic Facts about US healthcare system

ACA goals: 1. Set national standards for health insurance (solve the "underinsurance problem) 2. Require coverage or pay fee (actually a tax according to the Supreme Court) 3. Insurers guaranteed issue regardless of pre-existing condition 4. Subsidies for those on individual market 5. Expand Medicaid for lower income 6. Cover Rx drug "doughnut hole" healthcare in general goals: 1.Reduce morbidity/mortality from disease 2. Prevent disease 3. Control cost 4. Distribute benefits widely (universally - ideal) 5. Stability

Definition of Equipoise

Clinical equipoise is the assumption that there is not one 'better' intervention present (for either the control or experimental group) during the design of a randomized controlled trial (RCT). A true state of equipoise exists when one has no good basis for a choice between two or more care options is the assumption that there is not one 'better' intervention present (for either the control or experimental group) during the design of a randomized controlled trial (RCT). A true state of equipoise exists when one has no good basis for a choice between two or more care options.

Jessica Cohen - Grade A: The market for a yale woman's eggs

Cohen, a Yale student, tries to donate her eggs to a couple, but the couple is very strict on their ideal donor and has too many requirements so they can have the "perfect egg" (child). Creating the perfect child would lead to "a child encumbered with too many expectations." conceiving through donors and looking for the perfect one leads to a life of pressure and unrealistic perfection for the child.

John Arras: Case study: the jewish chronic disease hospital case

Injected elderly with HeLa cells, resulting in cancer for the subjects. Wanted to study how elderly fight cancer.

Gillian brock and Michael blake - the brain drain

Many of the best and brightest citizens of developing countries choose to emigrate to wealthier societies, taking their skills and educations with them. What do these people owe to their societies of origin? May developing societies legitimately demand that their citizens use their skills to improve life for their fellow citizens? Are these societies ever permitted to prevent their own citizens from emigrating?

michael Sandel - the case against perfection: what's wrong with designer children, bionic athletes, and genetic engineering

Michael Sandel argues that the pursuit of perfection is flawed for reasons that go beyond safety and fairness. The drive to enhance human nature through genetic technologies is objectionable because it represents a bid for mastery and dominion that fails to appreciate the gifted character of human powers and achievements. Carrying us beyond familiar terms of political discourse, this book contends that the genetic revolution will change the way philosophers discuss ethics and will force spiritual questions back onto the political agenda. In order to grapple with the ethics of enhancement, we need to confront questions largely lost from view in the modern world. Since these questions verge on theology, modern philosophers and political theorists tend to shrink from them. But our new powers of biotechnology make these questions unavoidable. Addressing them is the task of this book _______________________ Breakthroughs in genetics presents us with promise and a predicament. Why do we have this moral queasiness? Sandel- incorrect arguments for moral queasiness - 1st argument- Autonomy -denies children an open future -not persuasive bc children already cannot choose their genetics. no one can choose inheritance. -limits autonomy and influences free choice -doesnt explain why ppl seek genetic enhancements for themselves. these ppl make an atomic decision. 4 cases that highlight problems with enhancement: 1. muscle- we already have unfair advantages. others are already more talented 2. memory- would it divide society? 3. height- if its freely offered to everyone ppl would still be uncomfortable with genetic enhancement so this doesn't answer the question 4. sex selection 2nd argument- form diminishing agency -threaten capacity to act freely and responsibility and hard work -you wouldn't really earn it, no hard work or pride in your success -diminish our agency- less responsible for what we do -closer to an agreeable reason Sandel's reason for moral queasiness - If we allowed genetic enhancement we would lose our appreciation for the GIFTED QUALITY OF LIFE. -and human powers and achievement -it would change our human character and disposition -we must recognize our talents and efforts and appreciate our gifts -luck and fate sometimes control our life -natural gifts -we appreciate beautiful ppl even though they did nothing to earn it -drugs cut out effort-short cuts-depreciates talent -effort + natural gifts = success and pride -parents accept and love children for who they are "gifted quality of life is ________" - open to the unbidden= open to chance, we don't have control. -if we chose our kids genetics it would disfigure the mother-child relationships. Sandel quote - triumphs willfullness over giftedness mold rather than behold we would lose gifts and efforts our moral landscape would change How would GE change our moral landscape - 1. affect humility- humility is a disposition worth having 2. responsibility- you are responsible for all your traits and who you are with GE . solidarity as humans- would eliminate chances. no need for health care, life would have less risk

Military Tribunal I: The Nuremberg Code

Voluntary consent of the human subject is absolutely essential Results should be for good of society Results should be based on the results of animal experimentation voluntary consent of human subject is absolutely essential, This means that the person involved should have legal capacity to give consent

History of Research Abuse

World War II, 1946 "Doctor Trial" in Nuremberg - USA v Karl Brandt 23 Physicians accused of war crimes/crimes against humanity for participation in negative eugenics program, human rights violations, and research on prisoners in concentration camps. Major Outcomes: first physicians found guilty of crimes against humanity for research, evidence of unethical Nazi experiments, and the Nuremberg Code. Block 10 of Auschwitz: Sterilization and castration experiments. Radiation exposure, pharmacological interventions, surgeries. Execution and dissections.

The second principle of justice

any social and economic inequalities MUST be arranged so that they: (a) Are attached to positions and offices open to all ("fair equality of opportunity"). (b) work to the benefit of the least advantaged group in society. (Maximin)

** Bonnie Steinbock - Payment for egg donation

argues for continued respect for individual choice regarding reproduction, but also that a right to reproduce should be recognized and supported only were there is an intention or ability to raise a child reflecting concern for potential harms to children (Steinbock) What does "respect for embryos" mean in the context of stem cell research? Main argument: Stem cells have moral value, but not full moral value, thus we cannot use them in frivolous ways, but we can still use them for research especially if that research would bring significant benefits in treating disease and prolonging rights support: 1) in order to have a Right to life one must have ends of their own and embryos do not have this so no right to life but still have a moral status 2) no difference between embryos left over from reproductive efforts or whether they are explicitly used for research argues that research that saves lives worth destroying embryos, but also possible that outcomes of stem cell research could cause more harm then good - in that situation destroying embryos wouldn't be worth it

Liberal Eugenics

Liberal is freedom to decide if you want to test your embryo for Down syndrome or something if you want to abort

Genetic Determinism

salvulescu: enhancement and treatment are the same. treatment: remove a deficit enhancement: add to a non deficit state he's like nah, it's all the same as private schools or tutors or whatever. "Modern eugenics in the form of testing for disorders, such as Down syndrome, occurs very commonly but is acceptable because it is voluntary, gives couples a choice of what kind of child to have, and enables them to have a child with the greatest opportunity for a good life." -Genetic Determinism (GD) is untrue, but a psychologically desirable for people in difficult circumstances (loss of child, reproductive problems, etc.) -leads to the exploitation of children by parents of clones

Belmont Principles in Research Context

*Response to Tuskegee, Willowbrook, JCDH and other violations of patient protection. Consent, independent review as control against deception, and positive risk/benefit ratio where central responses.* Respect for Persons/Autonomy Give weight to a person's judgments. What to do about compromised autonomy? informed consent: (1) Comprehension (2) Voluntariness Beneficence Encourage well-being and discourage harm. How do we justify exposing subjects to risk? What is the ratio of Risk/Benefit? Hard Limits on risks/burdens No brutality, and should burdens should be minimized What counts in the ratio? Cases: money, risk exposure (diffuse) In 2011 Seattle Bio-Med tested a recently developed malaria vaccine and called on volunteers in the area to be bitten by malaria infected mosquitoes. The strain of malaria was attenuated, posing low risk to subjects. This is known as "challenging" an experimental subject with the malaria parasite. For their participation, volunteers will receive approximately $4000 Justice Equity with respect to classes, and fair distribution (recruitment) What does justice demand in regard to the benefits of research?

bonnie steinbock - reproductive cloning: another look

-playing god is morally wrong, cloning is playing god, SO CLONING IS MORALLY WRONG reproductive cloning = Cloning for the purpose of reproduction. Therapeutic cloning = Cloning for the purposes of research, aimed at curing disease, preventing illness, and understanding pathology. Somatic cell nuclear transfer (SCNT) is the process by which Dolly was created. many folks against reproductive cloning are in favor of therapeutic cloning. STEINBOCK'S ARGUMENT: none of the arguments against reproductive cloning are persuasive. 1. safety: safety arguments are the same for human and animal cloning: the risks that have surfaced in the animals that have been cloned have not been excluded as risks for human cloning. Those dangers (premature aging, large offspring syndrome, possible problems in genetic imprinting and re-programming) seem to affect 23% of cloned animals -- a higher rate of birth defects than in normal reproduction. If the procedures improve, their safety might well improve as well. We have no evidence about whether human cloning would be safe. 2. claim that we are 'playing god' with cloning applies to any technology that changes outcomes, and many of those have already been completely accepted. There is no reason to expect that the individuality of a cloned child is threatened. There is no reason that there would be large numbers of identical individuals, since reproductive cloning would be on the initiative of infertile couples who wished a genetically related child, and that is hardly a situation that conduces to mass production. 3. assumptions that planned children are a parental project rather than individuals in their own right, depends upon a fallacy of genetic determinism. 4. human dignity is threatened by our choices about how to treat our fellow human beings and fellow animals and environment -- not by any causal analysis of their points or nature of origin. CONCLUSION: for the acceptable reason of cloning -- to get a genetically related child -- it's hard to see why cloning is more morally suspect than other ART. Parents who use children as means for their own ends are blameworthy no matter what the nature of the origin of the child. Safety reasons remain important considerations; but they do not constitute grounds for a permanent and absolute ban on reproductive cloning.

Kawachi's Three Myths about ill health

1. Genetics: Some people are simply disposed to use up lots of HC. why it's a myth: inadequate to explain different health outcomes 2. Irresponsible Behavior: The uneducated and the poor choose their own illnesses, using up lots of resources. why it's a myth: choice is missing in many cases (smoking in kids etc) and responsibility is very difficult to allocate 3. Lack of Access: Health care inequity explains bad outcomes why it's a myth: ignores social determinants of health. 1. poor health equals bad genes - our health performance, especially with respect to racial disparities in health, reflects inherited differences in health stock - according to this line of argument, our nation's lackluster health performance can be explained by the distribution of flawed genes in the population ex. the high incidence of obesity, hypertension, etc. can all be explained by a higher genetic predisposition within our communities (especially African American communities) to develop these maladies - this is disproved because: researchers have compared the occurrence of these diseases across the populations sharing the same genetic stock, but living in different societies - instead of bad genes myth we ought to be searching for what in our society is toxic to our health 2.poor people behaving badly - myth is that sick people ( especially poor and uneducated people) bring poor health upon themselves through ill-informed or irresponsible risk-taking behaviors - according to this view: individuals are free to choose their "lifestyles" as long as they take responsibility for the consequences of their own choices and dont expect other to pay for them some even say that our poor health is the price we pay for maintaining our health values - the long list of health barriers to adopting a healthy lifestyle should give pause to those among us who blame the poor health habits of fellow citizens on ignorance, sloth or indifference -- Ex. kids should play outside and exercise àcant because unsafe neighborhood àexample of a barrier 3.lack of access to health care - third myth is our lack of access to universal healthcare - there is no proof that universal healthcare would improve the health of those that don't have it - it is the fallacy of confusing the cure with the cause of an illness like blaming a patient's fever on the lack of deficiency of aspirin •according to some analyses: lack of primary healthcare accounts for significant part of the dismal American health care performance àimplies a radical redirection of current efforts to reform health insurance, including restricting medical care priorities in a system that is overwhelmingly focused on the delivery of specialist and hospital based

Explanation for US Healthcare expense

1. Markets are responsive to incentives. We have made terrible incentives. 2. View that More care=better care 3. Fee-for-service 4. Over-treatment and Under-prevention

Ichiro Kawachi: Why the U.S. is not number one in health

1. public ignorant of dismal health performance bc not regularly covered in the media -doug jones: average health and social performance (stagnant) 2. as long as life expectancy continues to grow US doesn't care about ranking -believe performance should be judged in terms of absolute gains in life expectancy but averages can obscure dramatic differences between groups (ethnic/social) 3. public misinformed about causes of poor health -myth: bad genes. poor health comes from poor people behaving badly. lack of universal access to healthcare bad genes: obesity, diabetes all due to higher genetic predisposition w/in communities (this is a misconception) poor people behave badly: ex smokers start underage, working of free market advertising of tobacco co earning and income inequality is the cause of bad health rankings in the US -pattern of economic growth lopsided (as private wealth becomes more concentrated, quality of public life suffers) -more unequal wealth distribution, higher death rate conclusion: Average economic growth does not matter to health because averages can hide deep divisions within society •Even though our economic growth has risen àthere is still inequality •Economic inequality makes Americans on the lower scale unable to purchase needed goods and health services •

Principle for allocation

1. treating people equally (lottery, first come/first serve 2. favouring the worst-off, (illest, youngest) 3.maximising total benefits (number of live saved, number of years) 4. promoting and rewarding social usefulness (instrumental value, reciprocity)

The first principle of justice

Each person is to have an equal right to the most freedom compatible with everyone else having that same amount of freedom.

alex london - bone marrow transplants for advance breast cancer

ALLOCATING SCARE RESOURCES (by Alex John London) Bone Marrow Transplants for Advanced Breast Cancer: The Story of Christine Demeurers Christine deMeurers had stage 4 metastatic breast cancer, and was a mother of 2, had a husband, and was a teacher. She and her husband had health insurance, but had purchased the cheapest plan available - Health Net. She and her family exhausted all standard therapies available, but there was a new procedure available (high dose chemotherapy with autologous bone marrow transplant) that offered some hope, although it had no proven benefit at the time. Their insurance denied coverage for the procedure since it was "not uniformly accepted as proven and effective for the treatment of metastatic breast cancer." The doctor who was going to give the treatment also happened to be a member of their insurance committee - conflict for the doctor between helping patient and upholding the policy he had a part in shaping. In the end, a third-party covered the costs (UCLA), and Christine had 4 disease-free months before succumbing to the cancer. - Issues illustrated by this case: We embrace values of frugality and fiscal sensibility, which lead us to protest high health care costs. At the same time, we won't accept any less than the latest and most sophisticated healthcare. - Should we, the government, or insurance pay for procedures of this nature? Should we pay for procedures of unknown benefit when there are people struggling to get procedures of known benefit? - Those with the resources and ability to articulate their compelling cases can receive access to these kinds of procedures while the less articulate and less well-off cannot. If we don't draw the line on medical expenses here, where will we? What makes a procedure considered experimental? - Towards a more just system Solution: If we give subscribers an active role in the formation of guidelines that govern their care (rather than deciding randomly what will be approved and why via people with money bringing their cases to court), insurance providers will give their subscribers a stake in making sure such guidelines are both fair and effective. It will ensure people are treated as ends in themselves and not as mere means. - Christine's insurance denied the HDC/ABMT procedure on the grounds that it was experimental. They can make a strong case for this via the following argument: There is only an obligation to pay for therapies that are proven to have some therapeutic benefit, since there are not even enough resources to cover everyone's access to these proven therapies. Thus, saying the procedure is experimental seems more of a straightforward descriptive claim than a controversial normative judgment as to the monetary value of the quality and length of someone's life

De Jure vs. De Facto and Local vs. Global

De Jure = De jure (hard lines, strict)- according to administration (experts, law, rights) De Facto = (soft lines/lenient)- community based, what is actually medically practiced (actual standard of care)

Radcliffe-Richards: The Case for Allowing Kidney Sales

Arguments AGAINST allowing kidney sales: (1) protect the poor against exploitation by the rich, for they are ignorant and economically coerced. BUT: if they can't sell organs, they are even more economically coerced, and if they are ignorant, education and counseling are advised to remediate that condition. (2) Allowing the sale of life-saving organs gives an advantage to the rich that is not available to the poor. BUT: what does not? and anyway -- we could separate purchase from distribution. For instance, some kind of central agency could purchase any that were for sale, and then distribute them equitably, instead of re-selling them to the wealthy. (3) organ giving should be altruistic (4) allowing the sale of organs would undermine community trust in medicine. BUT: why should it? medicine is rife with other commercialisms, and trust doesn't suffer (or if it does, this wouldn't make it suffer more). and if the organ supply were increased, people would regain confidence in the capacity of medicine to help them in some respects. (5) the sale of organs would exacerbate already-great society inequality. BUT: decent regulation could prevent that, conditions of purchase could be regulated.

Commodification/Steinbock's "Incomplete Commodification"

COMMODIFICATION: regarding some object as a commodity to be bought and sold when such regard is immoral. Paradigm example: "benevolent" slavery harmful exploitation is an exchange that is at least superficially consensual but harmful to one (usually vulnerable) party. Paradigm example: extremely dangerous jobs by someone in desperate poverty. INCOMPLETE COMMODIFICATION: distinguish "legitimate" activities involving the body from illegitimate (what should be for sale, waht shouldnt) The wrongness of exploitation involves either (a) unfair compensation that is too low (b) overpayment/inducement that would invalidate consent. So, it seems the wrongness of exploitation is split, and requires: A. An account of what fairness in markets is. B. An account of consent that is more strict than informed, un-coerced, voluntary choice. Compromise view: "Incomplete Commodification" : Compensation for medical expenses, risk, time. But not for particular traits. cap compnesation?

Erin and Harris - An Ethical Market in Human Organs

CONFINED MARKETPLACE. in order to establish an ethical market in human organs, we need a single purchaser in a confined marketplace with built-in regulatory safeguards. Moral risks have to do with international trafficking in organs. But if you have a confined market, you can set it up so that residents of a given area can donate and thereby become eligible to receive organs should they ever need them themselves. The problem with the present notion of "gift" is that there is absolutely no reciprocity of any sort; everyone is remunerated but the donor. That's patently unfair.

Salmon - compulsory vaccination and conscientious or philosophical exemptions: past, present and future

Compulsory vaccination has contributed to the success of immunisation programmes in the USA and Australia, yet the benefits from compulsory vaccination are not universally recognised. Some people--experts and the public alike--believe that the benefits of compulsory vaccination are outweighed by the associated ethical problems. A review of vaccination legislation in the UK, Australia, and the USA raises four main points. First, compulsory vaccination may be effective in preventing disease outbreaks, reaching and sustaining high immunisation coverage rates, and expediting the introduction of new vaccines. Second, to be effective, compulsory programmes must have a reliable supply of safe and effective vaccines and most people must be willing to be vaccinated. Third, allowance of exemptions to compulsory vaccination may limit public backlash. Finally, compulsory vaccination may increase the burden on governments to ensure the safety of vaccines. Nevertheless, although compulsory immunisation can be very effective, it might not be acceptable in some countries where high coverage has been achieved through other approaches or efforts, such as in Sweden, Norway, Denmark, the Netherlands, and the UK. These factors should be considered when compulsory vaccinations are being introduced or immunisation laws refined. Lessons learned from compulsory vaccination could be useful to other public-health programmes.

Gopal Sreenivasan - Opportunity is not the key

Daniels argues that health care is special because health is special. Health is special because it is required in order for an individual to have a fair opportunity for the goods of the society. Daniels connects health with healthcare, which he interprets as requiring universal access. BUT: if introduction of universal health care does not alter a society's gradient in health status; and if introducing a universal health system would seriously erode the society's capacity to deal with the other determinants of health status -- is a society really required to devote a disproportionate amount of the society's funds to a small percentage of the society's members (the diseased or disabled)??

Equality and Equity

Equality: cases are treated the same Equity: normative defense of appropriate standard. Treated the same with reference to some normative standard

President's Commission: An Ethical Framework for Access to Health Care

How ought health care be distributed? - -principle of equality: anyone receives the same level of care (strict egalitarianism, rejected as that restricts freedom). -accordance to need: everyone must receive all are that is beneficial to them. Not practical and too expensive, does not recognize other societal goals. -limited form of provision: provision of an adequate level of care, basic decent minimum to create fair opportunity. Free to purchase services on top of this. Advantageous as doesnt restrict liberty, allows pursuit of other societal ends. Why is health care an obligation? - Is a societal obligation -individual citizens cannot provide their own care: requires special knowledge, education and public resources. Requires social cooperation. -need is unequally distributed and unpredictable: cannot be predicted with accuracy like other needs. Reliance on society for help, requires social provision. -differences in health care are undeserved: not at the fault of citizens that they have worse health conditions. Responsibility for differences in Health Status - We still cannot identify all the factors, there are social determinants such as socio-economic factors or addiction. -diet: precise cause and contributing factors are more complex. Unlikely to be the sole cause (e.g. genetic disposition) -would be unfair to hold them fully accountable, there are still factor out of control that we have an obligation to

Norman Daniels: Equal opportunity and health care

Issue: access to health care we can't figure out what principles of justice should govern access to healthcare by consulting general philosophical theories of justice. We need to specify what kind of 'good' health care IS. Is it a commodity, like computers, to be governed by market logic? or does it have a special status due to its fundamental effect on wellbeing? The 'normal opportunity range:' the range of life plans reasonable persons in a society are likely to construct for themselves. FAIR EQUALITY of opportunity requires that opportunity be equal for persons with similar skills and talents. The principle that should govern the design of the health care system is the principle GUARANTEEING FAIR EQUALITY OF OPPORTUNITY. The moral function of a healthcare system must be to help guarantee fair equality of opportunity. two tier system: the basic tier (a) should include services that meet important health care needs that impact the opportunity-range and (b) should be considered a 'decent basic minimum' (c) to which there should be NO obstacles (financial, racial or geographical) to access. there can be a second tier -- less important needs or preferences, like cosmetic surgery, to which there can fairly be financial obstacles. Social obligations are focused on the basic tier, the 'decent basic minimum.' This principle requires emphasis on preventative measures and on public health measures. It does not give individuals a 'right' to have all their health care needs met. The principle of justice guaranteeing fair equality of opportunity shows that individuals have legitimate claims or rights when their opportunity is impaired in particular ways -- against a background of institutions and practices which protect equal opportunity. The scope and limits of these rights is relative to resource scarcity and technological development for a society.

Species Typical Functioning

Norman Daniels says: Societally relative standard of need - species typical functioning(STF): Normal opportunity range is the array of life plans for a reasonable human being. HC should give citizens access to the normal opportunity range for someone of her talent and skill. complications: what about things like disability? can we avoid normative judgments? (no?) what is "reasonable" opportunity range? a.Daniels and STF Are big theories of justice useful? (Libertarian, Utilitarian, Contract-theory) Societally relative standard of need b.species typical functioning(STF): Normal opportunity range is the array of life plans for a reasonable human being. HC should give citizens access to the normal opportunity range for someone of her talent and skill.(183) c.Complications Species Typical Functioning: What about disability? • What counts as a reasonable view of the range? • Typical how? Average? Can this avoid normative judgments? Pluralism about what a reasonable opportunity range is (classic problem with Rawls)

ronald dworkin - justice and the high cost of health

Ronald Dworkin claims that we can tell what sorts of health care justice requires that society provide for its members by using a "prudent insurance" ideal. I. "Everyone agrees that the United States spends too much on health care" and "Most people also agree that health care is unjustly distributed in America" i. "How do we decide what lesser level of health care justice demands even the poorest should have?" ii. "How much should it decide, as a nation, how much it should spend, collectively and on each citizen?" iii. "We cannot avoid the question of justice: what is "appropriate" medical care depends on what it would be unfair to withhold on the grounds that it costs too much" II. Introduces the "rescue principle" to refute it and make his own argument look better i. Life and health are "chief among all goods: everything else is of lesser importance and must be sacrificed for them" ii. "Health care must be distributed on grounds of equality: that even in a society in which wealth is very unequal and equality is otherwise scored, no one must be denied the medical are he needs just because he is too poor to afford it" iii. Useless standard for answering questions about rationing, although it "does offer an answer to the question of how much America should spend on healthcare overall: says we should spend all we can until the next dollar would buy no gain in health or life expectancy at all" because everything must be sacrificed for health; however, just because it is most important does not mean you can't overthrow it. The principle says everything must go until the end, and the equality point enters because every last dollar for everyone in the society. iv. "Rescue principle's answer to the question of how much a society should spend on health care overall must be rejected as incredible" and it "encourages the idea that justice has nothing to say about how much a society should spend on health care" v. Rescue principle says "if rationing is necessary, it should not be done, as it now largely is in the United States, on the basis of money" "What should the basis of rationing be?" Justice is how you distribute health care and the rescue principle would answer this; however, Dworkin thinks the problem Dworkin suggests that under his model people might well be willing to pay less in general for healthcare than they currently do in the US, and in particular less for end-of-life treatment or for treatments that improve quality of life only a little and at great expense Dworkin's theory is sensitive to people's true preferences and subjective value judgements. Dworkin appears to be concerned with what real people would do under ideal decision-making circumstances when he is illustrating how important individual choice is in the theory.

julian savulescu - genetic interventions and the ethics of enhancement of human beings

There has been considerable recent debate on the ethics of human enhancement. A number of prominent authors have been concerned about or critical of the use of technology to alter or enhance human beings. I want to argue that far from being merely permissible, we have a moral obligation or moral reason to enhance ourselves and our children. Indeed, we have the same kind of obligation as we have to treat and prevent disease. Not only can we enhance, we should enhance. What is the issue Savalescu presents? - Is it morally permissible to genetically modify human beings at the beginning of their lives. What is Savalescu's thesis? - We have a moral obligation or moral reason to enhance ourselves and our children. Indeed we have the same kind of obligation as we have to treat and prevent disease. Not only can we enhance, we should enhance. Savalescu is more interested in the radical improvement in quality of life through biological manipulation. What is the arguments for enhancement? - To convince us that we also ought to modify for features that are essential to human happiness, not simple health. What is Argument 1? - Neglectful and Lazy Parents From argument 1, what are neglectful parents case? - Have a child with a stunning intellect that requires "A simple, readily available, cheap dietary supplement to sustain his intellect." They do not give the child the supplement and therefore the child only ends up having an average intelligence. From argument 1, what are lazy parents? - Have a child with an average intellect, but the same dietary supplement will raise the child's intellect to a stunning level. The parents can't be bothered to supply this supplement, so the child is left with an average intellect. What is Argument 2? - No difference between dietary supplements and biological (genetic) intervention. What is Argument 3? - No difference to Treating Disease What are the 4 ways that our genes & biology are determined? - Nature or god Experts Authorities By people themselves What are the 5 important rules that must be satisfied before a genetic intervention can be justified? - Safety Harm to Others Distributive Justice The parent's choices are based on a plausible conception of well-being and a better life for the child Consistent with development of autonomy in child and a reasonable range of future life plants. What are the responses to objections? - Playing God or Against Nature Genetic Discrimination The Perfect Child, Sterility, and Loss of the Mystery of Life Against Human Nature Enhancements are Self-Defeating choosing not to enhance is wrong - <positive argument> 1. the negligent parents act wrongly 2. the lazy parents act just as wrongly as the negligent parents --their inaction has "exactly the same consequence: a child exists who could have a stunning intellect but is instead normal" 3. parents who fail to take steps in genetic intervention act as wrongly as the lazy parents ---THIS argument succeeds so long as there is no difference between biological verses environmental interventions consistency - <positive argument> 1. some common, accepted environmental interventions impact our biology, sometimes irreversible 2. it would be inconsistent of us to reject genetic interventions on those grounds 3. there don't seem to be any other ground on which to reject genetic interventions no difference from treating diseases - <positive argument> 1. it all boils down to living a good life -we prevent disease because it prevents us from living a good life (or best available) -likewise, we should enhance ourselves in order to enable ourselves to live a good life 2. this does not just apply to using genetic interventions to prevent disease--it applies to all good-life-motivated interventions -temperament, personality, moral character playing God/ against nature - <objection> 1. everyone "plays God" all the time, and its fine --we are happy to use medicine to treat someone who is in the grip of a condition --it is no less an interference to take preemptive steps by genetically altering an embryo 2. not only is it not wrong to play God, it is sometimes morally required --sure, we should show some restraint by making sure we have an appropriate understanding of the risks, and weighing them against the benefits, but --once technology affords us the power to enhance our own and childrens lives, to fail to do so would be to be responsible for the consequences 3. "but there is value in variety that the natural order provokes" -the next stage will be rational evolution, according to which we select children..who have the greatest opportunities to have the best lives -evolution was indifferent to how well our lives went, we are not 4. we shouldn't make the mistake of assuming that the way things are is the appropriate default, and that we need a special justification to alter things genetic discrimination - <objection> 1. we should beware of creating a class. enhanced verses non-enhanced --reply to this is that we're already full up with in-groups and out-groups. this is nothing new --enhancement will if anything give our children a chance to avoid being discriminated against based on whatever suboptimal trait we improve enhancements are self-defeating - <objection> 1. if everyone enhances their children with the hope that they will be in the top quintile, the parameters of being in the top quintile will change as well, and 80% will inevitably fail --reply: some benefits are positional enhancing for positional benefits downs make sense, so be it --but other benefits are non-positional, and there is still an argument to enhancing to achieve those

Willfulness and Giftedness

Willfulness = Determination, effort, training, personal commitment. Giftedness = Mastery due to talent, innate ability, genetic

Direct/Indirect benefits of vaccines

direct: the person is immune. indirect: they cant give it to anyone or spread it so that helps the community.

Social Determinants of Health

inequality = reason for shitty US health program. (NOT poverty) Sreenivasan: Healthcare isn't special. Health is. And health is not primarily about healthcare. It is about social determinants! So, spend the ENTIRE healthcare budget on reducing social determinants, and you would have a world of greater fair equality of opportunity... access to safe neighborhoods, productive employment, freedom from discrimination, and full participation in the life of communities. ---then politics determines who gets what, how much, and when.

matt zwolinski - the ethics of price gouging

laws are unjustified consumers are simply given more options, if they agree then the benefit something is better than nothing price ceilings lead to shortages and less help down the road What does it mean to Price Gouge? - Create a sudden increase in prices following emergencies for necessities How many states have price gouging laws? - 34 What are the 3 kinds of arguments against Price Gouging? - If prices allowed to sharply rise: -buyers are coerced - Buyers are exploited - Unjust to poor and disadvantaged who will have difficulty affording necessities after natural disaster Evaluate Coercion Argument: - "your money or your life" -Coercer will harm you unless you give in to his demands -Coercer intends to control the actions of the coerced -Interaction is NOT mutually beneficial, person coerced is clearly worse off Point of objection for Coercion Argument: - buyers are genuinely consenting, but forced to act against their will Coercion Objection - If coercion requires threats, then exchanges and voluntary and not coerced. Analyze Exploitation Argument - A exploits B OR A takes unfair advantage of B DIFFERENT What are the 2 types of Exploitation? - Harmful: Zero or negative sum game. (ex. Slavery) Harmful often requires coercion Mutually Beneficial: (ex. saving someone who is drowning for $100)Both parties are better off, but one person gains more. If Price Gouging is Exploitation, which one is it? - Mutually Beneficial Exploitation What are effects of Price Gouging laws? - Either charges more money of customer or creates long lines and shortages if nothing is done. Price as a form of communication: - -Price signals induce people to respond to info that they don't typically possess -Prices economize on info What are price ceilings? - Maximum price set below the market price Effects of price ceilings: - -cause shortages (with free-floating prices shortages are absent) What is the return on Exploitation Issue? - Issue: No line with sharply higher prices versus long lines. OR rationing by price VS rationing by waiting in long lines What is the coercion Argument? - Remember- if coercion requires threats, then mutually beneficial price gouging is not coercion. - What id price gouging exchanges involve coercion of buyers who accept offers only because coerced by necessity? - STORM not sellers caused the necessity How could someone object to the previous statement? - Say: Sellers don't have to raise prices that sharply limits the buyers options But what happens if sellers don't raise prices? - Long lines and many buyers don't items they need- which seems a worse limitation to them Who supports not having Price gouging laws? - Horwitz and Yglesias What does Horwitz say about the laws? - Laws which cause rationing by wait don't make cost cheaper, makes it more expensive.

Carl Elliott - guinea-pigging

making a living off of participation in phase 1 clinical trials

Costs/Benefits of markets in organs

radcliff/richards: organ sales should be allowed joralemon: no it shouldnt