Introduction to

Ethics in

Health Sector

2

Why Is Ethical Analysis Needed?

Problems are not just technical How do we know which problems

are important? How do we know a good solution?

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Ethical Theory Alone Is Not Sufficient

Philosophical terms often are not clearly defined

Using ethical analysis to guide decisions requires practice

Moving back and forth between cases and theory can help

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Three Categories of Ethical Argument Consequences (outcomes):

Utilitarianism Rights (starting points):

Liberalism Virtues (character):

Communitarianism

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Each Perspective Has Unresolved Issues

How do we measure consequences?

Which rights do citizens have? Who defines the community and its

values?

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Utilitarianism

Policies should be judged by their consequences

What matters is well-being of individuals All individuals count equally The best action is decided by adding up

the gains and losses to all individuals “The greatest good for the greatest

number”

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It is better to be a human being dissatisfied than a pig satisfied; better to be Socrates dissatisfied than a fool satisfied.

John Stuart Mill - Utilitarianism

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How Can We Measure Utility?

Individuals evaluate their own situation: subjective utilitarianism

Experts devise an index to measure everyone’s well-being: objective utilitarianism objective utilitarianism

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Subjective Utilitarian

Ask consumers about their “willingness to pay”

Use data about prevalence, costs, and prices to calculate costs and benefits

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Problems with Subjective Utilitarianism

Suppose consumers are foolish or uninformed?

Does “willingness to pay” really measure changes in well-being?

How do we account for the fact that the rich can pay more?

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Objective Utilitarianism

Construct an index to measure health (e.g., Disability-Adjusted Life Years)

Calculate health losses for different diseases

Set priorities based on cost-effectiveness

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biggest bang for the buck

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Problems with Objective Utilitarianism Who determines the index? Accountability and transparency Technical decisions can mask value

choices: Time Age of death Disability vs. death

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General Problems with Utilitarianism Concerned with aggregate

welfare not with distribution Lack of respect for individuals Can justify inequality Technical calculations can mask

values

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Liberalism Individuals have the capacity to make

moral choices about life

Therefore, they are entitled to respect to choose their own life plan

Therefore, they have a right to preconditions for such choices

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What Rights Do People Have?

Negative rights - to be left alone, to be free to choose, to speak, buy and sell: libertarianismtarian

Positive rights – to resources needed for a reasonable range of opportunity: egalitarian liberalism

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Libertarians

Right to control your own body Right to purchase health care Priority to market, with minimal

state limits on individual choice No redistribution by state

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Egalitarian Liberals Basic right to opportunity: health

itself Role of state to redistribute

resources to assure fairness Example: Right to AIDS drugs for

worst-off in society

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Problems With Liberalism

What positive rights to citizens have in the health care arena?

Do we treat those who cause their own ill health?

What geographic scope for redistribution? Are universal rights another form of cultural

imperialism?

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Communitarianism Individuals live in society – not in

isolation A good society requires citizens

with “virtuous” character Society should instill virtue and

create a desirable social order

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Who Decides What Is Virtuous? Each society decides for itself what

is virtue (relative communitarianism)

There is one definition of virtue for all societies (universal communitarianism)

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Problems for Relative Communitarians

How do we know the boundaries of communities?

How far can communities go to suppress dissent?

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Problems for Universal Communitarians

Lack of tolerance for local or minority cultures

What happens when those with conflicting visions meet?

How do we know whose vision is correct?

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Broader Question of Broader Question of JustificationJustification

Faith Intuition Logic The World There is no justification

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Mixed Positions

Using more than one theory Principled construction of a mixed

ethical position – some examples: Utilitarian who respects some rights Egalitarian liberal sensitive to local

customs

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Implications (1)

You cannot make health policy without values

Conflicts in values often occur in making policy decisions

Conflicts occur even “inside” a theory because its implications may be ambiguous

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Implication (2) Ethical analysis can help identify

implicit values in varying policy positions

Ethical analysis can help someone clarify their own position

Ethical analysis can increase consistency, transparency, and accountability

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That’s all, folks!