introduction to health Ethics

1. 1. Introduction to ethics

2. Introduction …. • At one time, health care ethics was the domain of health care professionals • Doctors, nurses, and the other care givers in the allied health care professions made most of the decisions that pertained to the ethics of their occupations • While patients were often consulted about some of the medical decisions which affected them, they were usually passive insofar as ethical decisions were concerned

3. Introduction …. • Today, however, the situation has changed considerably • Because of the technical revolution in both information and in the provision of health care, patients are now an integral part of the medical decision-making process • Moreover, and perhaps more significantly, the ethical questions to which science, medicine, and health care give rise, affect the present and future well-being of people, whether they are sick or not

4. Introduction …. • For example, the manner in which health care is financed and provided now concerns everyone • The escalation of health care costs is fundamentally an ethical issue, as is the need to provide health care based upon human need rather than upon consumer ability to pay • Many situations arise in the practice of medicine and in medical research that present problems requiring moral decisions • A few of these can be illustrated by the following questions

5. Introduction …. • Should a parent have a right to refuse immunization for his or her child? • Is basic health care a right or a privilege? • Does public safety supersede an individual’s right? • Who dictates client care – the client, the physician, the attorney, or the medical insurance carrier? • Should children with serious birth defects be kept alive? • Should a woman be allowed an abortion for any reason?

6. Introduction …. • Should everyone receive equal treatment in medical care? • Should people suffering from a genetic disease be allowed to have children? • Should individuals be allowed to die without measures being taken to prolong life? • None of these questions has an easy answer, and one hopes never to have to deal with them • The decision for these issues is subjective, hence need to refer legal and ethical standards

7. Introduction … • ethics is a very personal concept and personal decision • Blanchard and Peale developed three questions to serve as an “ethics check” that is a useful tool for persons facing an ethical dilemma • is it legal or in accordance with institutional or company policy? • does it promote a win–win situation with as many individuals (client/employee/employer) as possible? • how would I feel about myself were I to read about my decision or action in the daily newspaper? how would my family feel? can I look myself in the mirror? • If the answer to any one of the three questions is no, the action is unethical • If the answer to all three questions is yes, the action is ethical

8. Introduction … • Coach Thee suggests that leaders, managers, health services providers and students ask and answer the following eight questions to test the rightness or wrongness of their actions • is it legal? • does it comply with my/our rules and guidelines? • is it in sync with my personal and organizational values? • will I be comfortable and guilt free if I do it? • does it match my commitments and promised guarantees? • would I do it to my family or friends? • would I be perfectly okay with someone doing it for me? • would the most ethical person I know do it?

9. Ethics and Morality • No matter what our social, cultural, economic or professional backgrounds are, we are all in the business of practicing ethics on a daily basis. • We have certain values (things we think are important for their own sake) and beliefs (views about the nature of existence and the way we understand the world to be) • For example, we hold values such as charity and generosity • Ethics is about carefully studying the values that actually do guide our attitudes and behaviors in given contexts, and it is about exploring what values ought to guide our attitudes and behaviors

10. Ethics and Morality … • ethics refers to standards of behavior that tell us how human beings ought to act in the many situations in which they find themselves as friends, parents, businesspeople, professionals… • Ethics is: • A moral Principle • What is good and bad • What is right and wrong • Based on value system

11. Ethics and Morality … • Ethical norms are not universal – depends on the sub culture of the society • Ethics is not following the law • Ethics is not following culturally accepted norms • Ethics is not science

12. Ethics and Morality … • Morality: is conformity to ideals of right human conduct • Morality is the quality of being in accord with standards of right or good conduct • Morality is looking at how good or bad our conduct is, and our standards about conduct • Ethics is used to refer to the formal study of those standards or conduct • Morals are the concepts of what is “good” and what is “bad” and how one should behave • Ethics is primarily a matter of knowing whereas morality is a matter of doing

13. What is Health Ethics? • Health ethics is the branch of ethics that deals with ethical issues in health, health care, medicine and science • It involves discussions about treatment choices and care options that individuals, families, and health care providers must face • It requires a critical reflection upon the relationships between health care professionals and those they serve, as well as the programs, systems, and structures developed to improve the health of a population

14. What is Health Ethics?... • few specific examples of health ethics issues include: • Making decisions about end-of-life care • Determining whether to allocate funds to the treatment of disease or the promotion of health • Critically examining the discrepancies in health status between populations and our ethical obligations to ensure equitable access to health services • Ensuring ethical conduct in health research

15. health ethics and the law • Laws are societal rules or regulations that are advisable or obligatory to observe • Ethics is a set of moral standards and a code for behavior that govern an individual’s interactions with other individuals and within society • Laws are mandatory rules to which all citizens must adhere or risk criminal liability • Ethics often relate to morals and set forth universal goals that we try to meet, • However, there is no temporal penalty for failing to meet the goals as there is apt to be in law

16. health ethics and the law… • Both ethics and law are normative frameworks, i.e. they define how people ought to act • Ethics and law are often complementary; for example, a legal decree might require a person to do what is ethically required (such as refrain from harming others) • However, something can be legal and yet conflict with ethical standards and vis-versa • For instance, there are no laws prohibiting countries from investing vast public resources in the development of medical interventions of minor public health significance, such as a cure for male pattern baldness

17. health ethics and the law… • It is not ethical to devote their resources to minor public health significance rather than reducing the burden of life threatening disease • disrespectfully to one’s parents may be considered unethical, even though it is not against the law • It is also possible that individual laws may themselves violate important ethical principles • Ethical analysis of the law can stimulate important reform efforts or acts of civil disobedience • while ethics and law are different, ethics remains a foundation for law, and often provides a justificatory basis for legal norms

18. Rationale of Health Ethics • Nowadays, conflicts of interests between the government and medical institutions, between medical institutions and medical personnel, between physicians and patients are getting more and more serious and complex • High technologies not only brought us hopes of cure but have also created a heavy economic burden • The ethical dilemmas of high technology medicine-brain death, organ transplantation, and concerns about quality of life-have become increasingly prominent

19. Rational… • The attainment of highest possible level of health is highly dependent, among other things, on the regulation of health service delivery and the application of suitable ethical principles • Ethics is and always has been an essential component of medical practice • Ethical principles such as respect for persons, informed consent and confidentiality are basic to the physician-patient relationship

20. Rational… • The study of ethics prepares public health professionals, health and medical practitioners and students to recognize difficult situations and to deal with them ina rational and principled manner • Ethics is also important in professionals’ interaction with society and their colleagues and for the conduct of medical research • It provides standards of behavior for health workers

21. Fundamental ethical principles • Four fundamental principles of ethics have usually been recognized and widely discussed in moral literature: • Autonomy, • Beneficence, • Non-maleficence, • Justice

22. Autonomy • Two Greek words: autos (“self”), and nomos (“rule”), giving it the literal meaning of “self-rule” or “self-governance”. • Implies an individual who is master of himself or herself and can act, make free choices and take decisions without the constraint of another • Respect for Persons: • autonomous agents, • persons with diminished autonomy are entitled to protection • Respect for autonomy is the basis for informed consent

23. Autonomy… • The application starts with the respect for a person’s right by providing them with adequate and relevant information • The process of informed consent is begun when initial contact is made with a prospective subject and continues throughout the course of the study – in research • Pre-conditions of autonomy are • Competence (the capacity to be a moral agent) • Liberty or freedom • Individual autonomy may be diminished or completely absent, as in the case of minor children, mentally handicapped or incapacitated persons, prisoners, etc.

24. Informed consent • The application of autonomy is seen in the informed consent process • Informed consent in ethics usually refers to the idea that a person must be fully informed about and understand the potential benefits and risks of their choice of treatment • Uninformed person is at risk of mistakenly making a choice not reflective of his or her values or wishes • Patients can elect to make their own medical decisions, or can delegate decision-making authority to another party • The value of informed consent is closely related to the values of autonomy and truth telling • "informed consent" correlates to informed refusal

25. Beneficence • The term beneficence refers to actions that promote the well being of others • Beneficence, or doing good, involves promoting another’s welfare, • In the medical context, this means acting in an individual's best interest and in a manner which benefits others • doctors must take positive steps to help people and not merely refrain from harm • However, uncertainty surrounds the precise definition of which practices do in fact help patients

26. Non-maleficence • the concept of non-maleficence is embodied by the phrase, "first, do no harm," or the Latin, primum non nocere • Many consider that should be the main or primary consideration (hence primum): that it is more important not to harm your patient, than to do them good • This is partly because enthusiastic practitioners are prone to using treatments that they believe will do good, without first having evaluated them adequately to ensure they do no (or only acceptable levels of) harm

27. Non-maleficence… • Much harm has been done to patients as a result, as in the saying, "The treatment was a success, but the patient died“ • It is not only more important to do no harm than to do good; it is also important to know how likely it is that your treatment will harm a patient • In practice, however, many treatments carry some risk of harm • In some circumstances, e.g. in desperate situations the outcome without treatment will be grave, • Hence, risky treatments that stand a high chance of harming the patient will be justified, as the risk of not treating is also very likely to do harm

28. Non-maleficence… • So the principle of non-maleficence is not absolute, and balances against the principle of beneficence (doing good), as the effects of the two principles together often give rise to a double effect • Double effect refers to two types of consequences that may be produced by a single action, and in medical ethics it is the combined effect of beneficence and non-maleficence • Depending on the cultural consensus conditioning (expressed by its religious, political and legal social system) the legal definition of non-maleficence differs • Violation of non-maleficence is the subject of medical malpracticelitigation • Regulations therefore differ over time, per nation

29. Justice • Justice is “fairness” or “entitlement” • we have an obligation to treat all people equally, fairly, and impartially • Justice requires that “equals be treated equally and un-equals unequally” • Implies that human beings as moral equals should be treated equally unless there is a reasonable justification for treating them differently • The general moral idea underlying the principle of justice is that which states: “Do unto others as you would have them do unto you if you were in their place and they in yours”

30. Justice… • The principle of justice demands • fairness in the treatment of individuals and communities • the equitable distribution of the burdens and benefits of research • Has important implications for such issues as • choice of study population, • recruitment into study, • study and post-study benefits, etc.

31. Conflicts between autonomy and beneficence or non-maleficence • Autonomy can come into conflict with beneficence when patients disagree with recommendations that healthcare professionals believe are in the patient's best interest • When the patient's interests conflict with the patient's welfare, different societies settle the conflict in a wide range of manners • In general, Western medicine defers to the wishes of a mentally competent patient to make their own decisions, even in cases where the medical team believes that they are not acting in their own best interests

32. Conflicts between autonomy and…. • However, many other societies prioritize beneficence over autonomy • Examples include when a patient does not want a treatment because of, for example, religious or cultural views • in the case of euthanasia, the patient, or relatives of a patient, may want to end the life of the patient • Also, the patient may want an unnecessary treatment, as can be the case with cosmetic surgery; here, the practitioner may be required to balance the desires of the patient for medically unnecessary potential risks against the patient's informed autonomy in the issue

33. Conflicts between autonomy and…. • A doctor may want to prefer autonomy because refusal to the patient's self-determination would harm the doctor-patient relationship. • individuals' capacity for informed decision-making may come into question during resolution of conflicts between autonomy and beneficence • The role of surrogate medical decision makers is an extension of the principle of autonomy

34. Fundamental ethical… • The four fundamental principles of ethics are equally relevant and important within all possible contexts and perspectives • They are cross-culturally valid, although the emphasis given to each and the way they are operationalised may differ slightly from culture to culture, from place to place, from context to context, and even from time to time within the same context

35. 4 ethical rules • Veracity – truth telling, informed consent, respect for autonomy • Fidelity – loyalty, maintaining the duty to care for all no matter who they are or what they may have done • Privacy – a persons right to remain private or one is not observed or disturbed by others during service delivery • Confidentiality – only sharing private information on a ‘need to know basis ”_disclose patient information based on need

36. Ethical Theories • Ethical theories provide a system of rules or principles as a guide in making decisions about what is right/wrong and good/bad in a specific situation • Applied consistently to determine whether an action is right or wrong • Allow a person to present a persuasive, logical argument as to why certain actions should or should not be allowed • Allow an executive branch to enforce conduct, i.e. to penalize persons for actions that are not allowed

37. Ethical theories … • There are many ethical theories • Consequentialism • Deontology • Virtue Ethics • Natural Law • Relativism • Divine Command Ethics • Principilism

38. Ethical theories … • There are three main approaches to ethics: • Consequence-based approaches • Rule-based approaches • Character-based approaches • The first two approaches address the question of how we should act (CONDUCT) • The third approach responds to the question of what kind of person we should be (CHARACTER)

39. Fundamental Question What kind of person we should be? Ethical theories … on the basis of consequences How should people act? by following rules and thus doing our duty develop character and virtues

40. Consequentialism: • Look at the consequences and choose the action that has the best consequences Act-orientedapproaches • Deontology: • Look at the rules and follow the rules (ten commandments, duty, human rights, justice). Ethical theories … • There are two basic ways of answer the question, “How should people act?” 40

41. Consequentialism theory • The rightness or wrongness of an action is determined by its consequences • Consequentialists maintain that whether an action is morally right or wrong depends on the action's consequences • In any situation, the morally right thing to do is whatever will have the best consequences • Consequentialist theories are sometimes called teleological theories

42. Consequentialism … • What Kind of Consequences? • Pleasure/pain • Happiness • Preferences/satisfaction • For whom the consequence is? • For the individual/me • For my group • For all human being

43. Consequentialism… • Based on the consequence to whom, consequentialism can be classified as: • Utilitarianism • The right action is the one that promotes the greatest happiness of the greatest number (maximizes social utility) • the choice that yields the greatest benefit to the most people is the one that is ethically correct • Bentham (1748-1832) and Mill (1806-1873)‏

44. Consequentialism… • There are two types of utilitarianism, • Act utilitarianism • An action is right or wrong to the extent that it increases or decreases the total happiness of affected members of society • Rule utilitarianism • Adopt moral rules which, if followed by everyone, will lead to the greatest total happiness of society • Principle of utility applied to moral rules, not individual actions

45. Consequentialism… • Ethical egoism - the ethics of self- interest • The right action is the one that promotes the greatest happiness of the agent (maximizes the agent’s utility) • everyone ought always to do those acts that will best serve his or her own best self-interest • morally right actions are those that maximize the best interest of oneself, even when it conflicts with the interests of others • Two Ethical Egoists - Benjamin Tucker (1854-1939) and Ayn Rand (1905-1982)

46. Consequentialism… • Altruism - show concern for best interests of others • Altruistic acts involve putting other people’s interests ahead of our own • The ethics of altruism prescribes that we sacrifice our interests and lives for the good of others • Ethical egoist theorists are strongly against to the ethics of altruism

47. Deontology • Deontology theories are rule oriented • The duty ethics theory, proposed by Immanuel Kant (1724-1804) • The rightness/wrongness of an action is determined by inherent features of the action itself, or by an inherently valid rule • If an action is of the wrong kind, it is forbidden, no matter how good its consequences are • Rejects both Utilitarianism and Ethical Egoism • “The end doesn’t justify the means”

48. Deontology… • The ethical action is one taken from duty, that is, it is done precisely because it is our obligation to perform the action • Behaving ethically by meeting our duties • Ethical obligations are the same for all rational creatures (they are universal) • For Kant, choosing to obey the universal moral law is the very nature of acting ethically • Duties such as, ‘being honest’, ‘not cause suffering of others’, ‘being fair to others, keeping promises’ etc. are ethical and right actions must be universalizable

49. Virtue Ethics • The rightness or wrongness of an action is determined by the character traits it expresses • Emphasize what kind of person you should be • The qualities that one should develop in oneself are called virtues (ex. honesty, fairness, kindness, prudence, faithfulness, generosity, integrity, bravery, etc.) • ethics should be concerned with the whole of a person’s life, not with the individual discrete actions a person may perform in any given situation • Aristotle (384-322 BCE) Confucius (551-479 BCE)

50. Ethical Relativism • This theory holds that morality is relative to the norms of one's culture • states that before decisions are made, the context of the decision must be examined • there are no absolute truths in ethics and that what is morally right or wrong varies from person to person or from society to society • variances in culture and society influence whether an act is moral • Unlike deontology, this theory believes that what is right for one group may not be right for another; this theory believes there is no “universal truth”