The Place of Clinical Bioethics in Health Care Ethical Issues and Philosophy

in Health Research in ` Developing Countries

Dan W. Brock Harvard Medical School

Introduction

Place of clinical bioethics in health care

Why has it been a growth industry? Will it continue to be? New technology has brought new choices

Relation of bioethics to philosophywhy does clinical bioethics need philosophy?

Often, there is no clear, uncontroversial answer about what to do

Development of Bioethics
I Professional Code of Conduct
Example: May doctors advertise?

II Public Debate over Clinical Issues

Example: Who decides when to pull the plug?

III Structure and Financing of Health Care System

Example: What is a fair system of health insurance?

IV Population-level Bioethics
Example: when are health inequalities unjust?

Why Arent the Ethical Views You Already Hold Enough?

The problem of uncertaintywhere youre unsure about some ethical issues.

E.g. terminal sedation

The problem of disagreementthere is sometimes deep disagreement on ethical issues, e.g. PAS

Some disagreement is about facts But other disagreement is about moral permissibility

Justification

The problem of justificationeven if you know what you think, and others agree, how do you know your view is justified or correct?

Empirical judgmentsthe screen is rectangular refer to descriptive properties Moral judgmentsdestroying embryos is wrong

wrong seems to have no empirical reference So does it only express your attitudeyoure against destroying embryos?

Ethical Reasoning

How is it different from matters of taste?

For example, with taste (I like chocolate, you like vanilla) we think theres nothing more to be saidwe just disagree and there is no correct taste Some imply they arentwisdom of repugnance But they areethical judgments/beliefs require reasons.

How are ethical questions different?

A Why? is always appropriate. Reasons will be general properties of actions, persons, etc.

Example of Abortion

Sallys abortion was wrongWhy? Because it is killingbut not all killing is wrong, e.g. bacteria. But abortion kills a human being?

Fetus is human, but what about humans makes killing them wrongspeciesism? Consciousness, self-consciousness, rationality, agency, etc? But a fetus seems to lack theseso is a fetus a person?

Abortion cont.

Even if a person, not all killing of persons is wronge.g. self defense when womans life at risk Does a woman owe the fetus 9 months use of her bodye.g. if she took precautions to avoid becoming pregnant

Thomsons violinistuse of hypothetical cases

This is a process of clarifying the reasons for your moral judgments

Features of Moral Reasoning

Making the reason for the initial judgment more precise

So it fits the case at hand, but does not have unacceptable implications for other cases This is a requirement of consistencydoes your judgment in this case fit with your judgments in other cases?

E.g. relation between abortion and stem cell research

Features of Moral Reasoning--Cont

Reasoning should be interpersonalideal is to consider all reasons for and against your view

Know from experience, best criticisms often come from others Goal is judgments hold in good conditions for judging and after full consideration of all relevant reasons
No, some moral disagreement may be irresolvable But, it does clarify precisely what the disagreement is

Does this guarantee agreement?

Features of Moral Reasoning--Cont

Does this guarantee your view is now correct?

No, if disagreement remains, both parties cannot be correct Know may reconsider later on basis of new reflection or experience Yes, it is what you hold after full consideration of all relevant reasons and arguments

Does this make your view justified?

So there is nothing left to consider

Made in relatively ideal conditions for judging Is what youre prepared to judge yourself and others by

Features of Moral Reasoning--Cont

This view is subjectivistimplies your moral beliefs justified if they survive this process

But another could end up with different and conflicting beliefs

Often resolves disagreement, but no guarantee it does Fits idea there is often reasonable ethical disagreement

But not subjective in crude senseyou have your views, I have mine, nothing more to be said

That would make ethics like matters of taste, and ignores the reasoning.

Features of Moral Reasoning--Cont

It is not relativismwhat is ethically correct is relative to a particular culture, group, individual

Relativismaction A is right in group M, wrong in group N; standards are relative to the group. On relativism Ms say A is right, Ns say A is wrong, and each are correct because their views are judged by their different standards So they are not disagreeing Relativism is mistaken

Features of Moral Reasoning--Cont

NOTE--giving reasons is the beginning of theory construction

Reasons can apply to other cases For example, right of persons not to be killed

Applies to wide range of cases Has other featuresrights can be waived, exercised, forfeited, etc Rights make person small scale sovereign in area of the right Focus on victim of rights violation

Features of Moral Reasoning--Cont

Cf. different duty based account of wrongness of killingalways wrong to deliberately take innocent human life

Focuses on duty of agentnot waivable by victim

Cf. different goal based accountloss of the good of a life is bad, minimize this loss of value

So, could kill one to save more.

Application to euthanasia Rights, duty, and goal-based views are different very general moral theories.

How Should Your Hospital Distribute Antivirals in an Avian Flu Pandemic?

For the past several months, there has been sustained human-tohuman transmission of a novel strain of avian influenza A with genetic components of human influenza in several countries around the world. Your community was first affected three weeks ago, and since then there have been over 500 cases and 50 deaths. Oseltamivir phosphate is the only drug that may effectively reduce mortality of ill patients and limit infection of exposed persons. However, supplies of oseltamivir are limited, and hospitals across the country are independently making decisions to govern allocation of antivirals within their institutions. In your community, the four major academic medical centers have recently established four different protocols regarding prioritization of access to care:

Hospital A
Recognizing the importance of protecting its workforce in order to minimize absenteeism and ensure continuous response capacity, Hospital A has decided to use its remaining cache of oseltamivir for prophylaxis of staff who are exposed while caring for influenza patients.

Justifications

Special responsibility to those who ask to take extra risksthey deserve extra concern Ensuring staff health will maximize their ability to care for pts and so maximize health outcomes

But will prophylaxis of staff actually maximize benefits?

Hospital B
In an effort to save its very ill patients, Hospital B has decided to reserve its remaining cache of oseltamivir for treatment of the sickest influenza patients. This approach is consistent with the usual practices of providers at Hospital B, who are accustomed to focusing primarily on treatment. Hospital B is relying on airborne infection isolation and personal protective equipment, namely N-95 respirators, gloves, and gowns to protect its staff, and is not using oseltamivir for prophylaxis.

Justification

Most theories of justice give special priority to the worse off. E.g. Prioritarianismbenefiting people matters more morally the worse off those people are

But how much health benefits should we be prepared to sacrifice to treat the worst off?

Hospital C
In order to maximize survival rates, Hospital C has decided to reserve its remaining cache of oseltamivir for treatment of the patients most likely to benefit, namely those who present within 48 hours of disease onset. As this prioritization plan will result in faster depletion of the antivirals, Hospital C is relying on airborne infection isolation and personal protective equipment, namely N-95 respirators, gloves, and gowns to protect its staff, and is not using oseltamivir for prophylaxis.

Justification

This may save the most lives possible But does this maximize benefits?

Should it matter how long survivors are likely to live? Should it matter what their QL is likely to be? Should their social value count? For example, if they are scarce health care workers?

Hospital D
Assuming that its cache of oseltamivir will soon be depleted regardless of distribution strategy, Hospital D is using the antiviral for prophylaxis of exposed staff and treatment of all probable and confirmed cases, regardless of severity. This is the most comprehensive approach, but Hospital D will reach limitations most quickly.

Justification

First come/first served among all in need of care

To give all in need of care a fair chance to get what they need To avoid making other distinctions

Hospital E

Hospital E has decided to give preference to younger patients who have been exposed and not to treat patients over 70

Justification

Patients who die at a younger age will have had less of the good of life years than older patients.

Each person deserves a fair chance to live a full human life span Different conception of fairness than hospital Ds

Notethis is different than maximizing life years gained

What does this case show?

In thinking through how to distribute antivirals in a pandemic, one quickly finds oneself addressing broader question of justice

Should we simply seek to maximize benefits? Only health benefits, or other benefits such as economic benefits as well? Do those who put themselves at risk to help others deserve special concern to? What does fairness require in prioritizing the use of antivirals?

Conclusion

My aim has been:

To briefly illustrate the nature of ethical reasoning To show how ethical beliefs can be justified To show how you inevitably find yourself dealing with issues in ethical theory

Next lecture will be about different ethical theories