Bioethics Flashcards
Descriptive ethics
How things are and how we think
Aim to describe and explain moral views that people do have right now
Normative ethics
How we should think
What moral views ought to be expected
Which views are justifiable
Moral philosophy (ethics)
Core questions about how we make decisions in daily lives and in society
Respectful ways
Epistemic humility
There is a lot we don’t know
Have to be open to the possibility that you might be wrong and your position could change
What is morality?
A set of fundamental rules that guide our actions
Morally forbidden
You must not do X
Morally obligatory
You must do X
Morally permissible
Morality permits you to do X
It would be nice if you did X
Morally supererogatory
Ethical imperialism
Belief that you are right and have the right to enforce your beliefs on others
Cultural relativism
Different cultures have different moral codes
Ethical relativism
There is no objective truth in morality
Right and wrong are only matters of opinion, and opinions vary from culture to culture
6 problems with ethical relativism
- Can’t criticize other cultural practices or beliefs; they are “just different”
- Fails to appreciate common ground
- Contrary to appearances, it doesn’t make people tolerant
- Doesn’t fit with our ethical practices
- Unclear whether/how moral progress is possible
- Which society/culture?
Philosophical high ground
Appeal to reasons, follow reasons, acknowledge you can be wrong
Utilitarianism
Consequences/outcomes are all that matter
Actions should be done that have the greatest benefit possible
Consequentialism + theory of the good
Impartially rendered (your happiness is not more important)
Principle of utility
A person ought to act so as to maximize utility
Utility
The net balance of good over bad (ex: net happiness)
4 main problems with utilitarianism
- Calculations (how can you measure things like happiness)
- Special relationships (are you really not going to value some people more than others)
- Too demanding
- Rights/justice (what if something violates someones rights but makes people happy)
Deontology
Motives/intentions are all that matter
The consequences are not what we should focus on, just want the reasons to be right
Hypothetical imperatives
Things we think we ought to do
Linked to goals we have set for ourselves
If you want to do X then you should do Y
Categorical imperatives
Not dependent on us setting goals for ourselves
They arise because we have the capacity for reason
Just because we have reason we are bound to act certain ways in the world
Applies to all of us unconditionally
First formulation of categorical imperative
Act only according to that maxim whereby you can at the same time will that it should become a universal law
Before you do an action, think about what it would be like if everyone did that
Second formulation of categorical imperative
Act in such a way that you treat humanity, whether in your own person or in the person of any other, always at the same time as an end and never merely as a means to an end
Casuistry
Anti-theory theory
Case based reasoning
Instead of starting with a grand moral theory, just look at a case and figure out what’s right and then move on
Tendency to move towards this in bioethics
Respect for autonomy
Respect the decision-making capacities of autonomous persons
Enable individuals to make well-reasoned choices for themselves
Beneficence
Acts in a way that benefits the patient
Non-maleficence
Avoid causing harm to the patient
Justice
Treat like cases alike
Distribute benefits and burdens fairly
4 Principles of health care
Respect for autonomy
Beneficence
Non-maleficence
Justice
4 characteristics of rights (Arras)
Entitlement vis a vis other people
Moral versus legal rights
Positive versus negative rights
They are weighty and demanding
Rights and Correlative Social Duties (3 - Arras)
- Avoid violating negative rights
- Protect vulnerable parties against deprivation of their rights (need police/military)
- Assist those whose rights have already been violated (need court system)
2 and 3 require significant investment from the public
Negative rights
Basically the right to be left alone
Correlate with the duties of all others to refrain at all times from intervening against them
Easier to justify and fulfill
Ex: not be killed, not be stolen from
Positive rights
Require that other people provide the goods and services to which we are allegedly entitled
Ex: health care?
Function of rights
To resist the idea that people have to beg for the help of others
Matter of justice instead of charity
Libertarianism
Never going to give you a right to health care
“There’s nobody here but us individuals, and the one life we all have to live”
Everyone should be treated as an end themselves
Separateness of persons
Only rights we have are negative rights
Communitarianism
Traditional theories have been too focused on individual rights - should start by asking what kind of society you want to live in
Bundles a lot of theories
We can get to the idea of a good life and design a society that does that
Health care is a public need
Main problem: starting point violates conditional neutrality - it imposes conceptions of the good life on people
Liberal egalitarianism
Most dominant view today
What is required for fair equality of opportunity in society?
Rawls was major supporter
John Rawls
Defended liberal egalitarianism
We should think about the basic structure of society and what a well organized society would look like
Start with justice!
Accept and know others accept the principles of justice and know the basic structure of society satisfies principles of justice
Social contract theory
Moral equality of human beings
No human being is inherently subordinate to any other human or group of humans
How can free and equal people be governed?
Hypothetical social contract
Fact of reasonable pluralism
In a free society people will have conflicting moral values
These views are reasonable insofar as their adherents accept pluralism and are willing to live within the bounds of justice
Liberal egalitarianism
Hypothetical social contract
The “original position”
Imaginary scenario where citizens make social contracts with each other to set up a society from scratch
Agreeing together what the rules of society are going to be
Have to agree to disagree
Why use the ideal theory?
So that you can use it as a benchmark to assess actual societies
Justice as fairness
Justice is what free and equal persons would agree to as basic terms of social cooperation under conditions that are fair for this purpose
2 basic principles we are going to get from the social contract (and basically every theory can agree on)
- Liberty (as much freedom as people can have without impeding on the freedoms of other people)
- Equality (2 conditions)
2 Stipulations of the equality principle
Social and economic inequalities are to be arranged so that they are both..
- To the greatest benefit to the least advantaged (the difference principle)
- Attached to offices and positions open to all under conditions of fair equality of opportunity (principle of fair equality of opportunity)
Health care delivery in Canada
How the services are organized, managed, provided, etc
Mostly private
Health care financing in Canada
Also a mix, but mostly public (70%)
How medical services are paid for - taxation to support health insurance plans
2 reasons to resist commodification
- Certain types of good are closely connected to the integrity of person (organs. surrogacy contracts, babies)
- Collective action problems/efficiency (blood donation, nuclear waste disposal sites)
What is the main difference between food and clothing (as needs) and medical care (as a need)?
Predictability
You can plan for how much food or clothes you need, but you can’t plan how much health care you’re going to need
2 main problems with systems that dont have universal health care
- Adverse selection problems (concern about who gets insured - can deny people who have pre existing conditions or increase their cost a lot)
- Moral hazard (even once people are insured there is an incentive to deny their claims - administration costs are really high)
What year did health care come into effect?
1968.
Fully by 1972
5 Commitments of the CHA
- Public administration (the administration of the health care insurance plan of a province or territory must be carried out on a non-profit basis by a public authority)
- Comprehensiveness (all medically necessary services provided by hospitals and doctors must be insured)
- Universality (all insured persons in the province or territory must be entitled to public health insurance coverage on uniform terms and conditions)
- Portability (coverage for insured services must be maintained when an insured person moves or travels within Canada or travels outside the country)
- Accessibility (reasonable access by insured persons to medically necessary hospital and physician services must be unimpeded by financial or other barriers)
The Chaoulli Case
2005 - Zeliotis and Chaoulli
Challenged Quebec’s ban on private health insurance for services covered under the province’s public insurance plan
Finding: given long wait lists for certain health services, the ban on private insurance did violate the right to life, liberty and security of the person (in quebec charter)
Not found to violate canadian charter
3 conclusions from the Chaoulli case
- Wait lines are too long
- Private means they won’t have to wait too long
- No evidence that a private system will undermine the presence of the public system
Health definition according to WHO
A state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity
5 determinants of health
- social environments
- physical environments
- psychological environments
- productivity and wealth
- health care
5 basic assumptions of canadian health care delivery (armstrong and armstrong)
- The determinants of illness are primarily biological
- The engineering model of the body
- Health care is primarily about curing illness or disability
- Medicine is scientific
- The doctor as authority and expert
3 historical structures that caused issues with aboriginal health
- Diminished or eliminated access to subsistence activities
- Exposure to disease
- Cultural genocide
5 models to answer the question: are health risks voluntary?
- The voluntary model (yes)
- The [Former] medical model (no - but fails)
- The psychological model (maybe - but fails)
- The social structural model (no)
- The multicausal model (hard to tell)
Key findings on the American data on user fees
Participants who paid for a share of their health care used fewer health services than a comparison group given free care
Cost sharing reduced the use of both highly effective and less effective services in roughly equal proportions but it did not significantly affect the quality of care received by participants
It had no adverse effects on participant health, but there were exceptions: free care led to improvements in hypertension, dental health, vision, and selected serious symptoms
These improvements were concentrated among the sickest and poorest patients
Free systems help the poor and the sick the most
Absolute scarcity
Something that you cannot just put more money into and get more of
Ex: livers. Can’t just put more funding and get more livers
Glannon’s argument in general
Argues that in a tie breaker situation, people with ARESLD should be given lower priority
Assumes multicausal model
Causal
Connection between a behaviour and a result
Prioritarianism
Giving priority certain people
Can be worst off, or youngest first
5 things Persad combines to decide who gets the livers
Youngest first (but not infants, need the curve) Prognosis Save the most lives Lottery Instrumental value
2 common sources for kidneys
Living donors: family members/close friend (60%), social networks, paid donors
(Brain) dead donors
3 main concerns with kidney sales
- Exploitation
- Informed consent
- Commodification
Exploitation
When one party takes advantage of another’s economic need to secure something for considerably less than its value
Taking advantage of someone else
Ex: sweat shop labour
Radcliffe-Richards opinion on kidney sales
We would be doing more harm by removing the option to sell their kidney
It would leave them worse off than when they started
Informed consent versus token consent
Informed: actually understanding what you are consenting too
Token: just signing or saying yes without knowing everything
5 elements of informed consent
1) Competence (can they provide recognizable reasons for their decisions)
2) Disclosure (risks, benefits, and alternate options)
3) Understanding
4) Voluntariness (not coerced)
5) (token consent)
Coercion
Deprive of any option to make another choice
Commodity
A kind of thing produced for use or sale, an article of commerce, an object of trade
2 key objections to kidney sales
1) Fairness: asks about the inequalities the market choices can make (covers exploitation and coercion)
2) Corruption: covers commodification. Even if we could fix the fairness problem, this would remain a problem
Why worry about the fact that offering payment hinders achievement of goals?
Practical perspective: less efficient
Ethical perspective: ignores intrinsic value of nonmarket norms
3 requirements to have a valid consent
Capacity: the ability to understand the nature of the decisions you’re making and the consequences of that decision. It is a fairly low bar. Has nothing to do with the content of the decision
Information: do you know anything that a reasonable patient would want to know. The reference is the patient, not the doctor (if the patient wants to know more, they should)
Uncoerced: free of external influence (are we ever truly free of influence?). Concerns of inducement (subtly influencing the decisions of patients)
Informed choice
Consent and respect for autonomy
Ethically relevant differences
Differences in treatment should be responsive to differences in the situation
3 ways medical autonomy is justified
- Better outcomes overall; promotes disclosure and seeking of care
- Patients are better positioned to evaluate their overall interests
- Normative authority of patients to make decisions for themselves regardless of their interests
4 concerns with medical autonomy during childbirth
Lack of ability to make decisions
Inability to inform
Decision under duress
Emergency situations
Conscientious objection
Health care providers don’t have to do anything they are not comfortable with
Ex: abortion, circumcision, medical assistance in dying
Morally risky action
An action that has a high probability of resulting in a morally wrong outcome
5 criteria to determine the degree of moral risks
- Likelihood that act is wrong
- Severity of potential wrongdoing
- Cost of avoiding potential wrongdoing
- Responsibility for wrongdoing
- Moral risks of not acting
4 arguments for the right to do wrong
- Interference would constitute a greater harm overall
- Possibility of error regarding rightness/wrongness
- Better outcomes on balance
- Burden of intervention
Policy defintion
A course or principle of action adopted or proposed by an organization or individual
How should we respond to genetic info in terms of social policy? (2)
Mass screening
Antidiscrimination legislation
Geneticization
A tendency to use genetic explanations to characterize differences between individuals and groups.
It is the tendency to treat genetic information as special
3 things good/responsible parents are told to do
Avoid risk
Maximize benefit and advantage for children
Self-sacrifice
4 differences between people with disabilities and normal Canadian population
Lower educational attainment
Lower rates of employment
Lower income levels
Significant needs unmet
What do we screen/test for?
Prenatal (standard): Aneuploidy (trisomy 21, 18, 13), neural tube defects (spina bifida, anencephaly)
Newborn (once they’re born): metabolic disease (PKU, cystic fibrosis)
Adult-onset conditions: cancer (breast and ovarian), neurological disease (Huntington’s, Alzheimer), cardiac disease
5 ways to screen/test
Maternal serum test Ultrasound Non-invasive prenatal testing Chorionic villus sampling Amniocentesis
Who gets tested?
Individuals with screening results indicating higher risk (public funding) - used to be based on age, now its when the risk of miscarriage from testing is the same as the risk of having an affected baby
Individuals who can afford the cost ($400-700 for NIPT)
3 purposes of prenatal testing
Improve population health
Increased reproductive autonomy
Provide reassurance
3 concerns about prenatal testing
Justice
Expressivist objection
Slippery slope argument
Expressivist objection
Prenatal testing (and selective abortion) for a particular condition conveys the message that life with that condition is not worth living, and in so doing constitutes harm to people who are living with that condition
Positive versus negative eugenics
Positive eugenics: getting the “desirable” people to breed together
Negative eugenics: preventing “undesirable” people from breeding together
Distributive justice
Who does/does not have access to testing?
Presumption that testing is a benefit and some groups aren’t getting it
Social justice
Which groups bear burdens/benefits from testing?
We should distribute benefits and burdens fairly over groups
Corrective Justice
How do we rectify the effects of unjust distribution of resources and benefits/burdens?
Give certain groups more because they had less in the past
Equity, not equality
3 problems with prenatal testing from a justice point of view
- Resource allocation and opportunity costs
- Obscures social determinants of health
- Might preclude attention to other, lower-cost, more effective ways to improve health
2 problems with the way the general population looks at eugenics
- Simplistic understanding of genetics
2. The idea that we can select for the “good” genes
2 institutional solutions to protect women in childbirth
1) Cease practice of interventions being provided, non-consensually, on behalf of unborn children
2) Explicitly prohibit obstetric violence
4 Objections/Replies to saying people should have less actions to livers with ARESLD
- This policy is punitive
- Natural lottery/luck
- Fair warning condition needed
- Doctors will be denying life saving treatment
3 bodies making decisions and what they need to take into account
- Government: neutrality and whether it is providing something useful
- Individuals, for others: child’s right to an open future
- Individuals, for themselves: autonomy/harm
Treatment/therapy definition
An intervention aimed at treating disease and restoring physical and mental functions and capacities to a NORMAL baseline
Enhancement baseline
An intervention that augments otherwise normal physical and mental functions and capacities
4 theories of health related good
- Libertarianism
- Utilitarianism
- Communitarianism
- Liberal egalitarianism
Problems with enhancements (6)
Competitive advantage Self-defeating Risky Objectifying people Competitive disadvantage Expressivist objection/harmful stereotypes
Ethics vs laws
Ethics: when you need to reason through right and wrong and people might have different moral/ethical standards
Laws: differ between places and need to be reviewed because someone needs to make the law – so there could be problems with it
Causally vs morally responsible
Casually: when the disease is causally sensitive to chronic drinking, the chronic drinking is voluntary and the drinker is capable of understanding the consequences of those actions
Morally: when he/she is causally responsible and fails to act on the knowledge that chronic drinking can increase competition for competitive resources
