publicHealthEthics-course_Outline&Introduction

INTRODUCTION TO ETHICAL ISSUES IN PUBLIC HEALTH PRACTICE & RESEARCH

Ghaiath M. A. Hussein MBBS (ZAU, Sudan) MHSc. (Bioethics, U of T, Canada) MD (1st Part Comm. Med., SMSB)

JPCMFM, Jan 2- 5, 2010

CONTACT INFORMATION

[email protected]

Office hours by appointment

Ghaiath

Ethics in Public Health (JPCMFM) Jan.2010

ACKNOWLEDGMENT

• Most of the slides used in this presentations are used with permission from:

• Barbara Secker (JCB); and• Lawrence M. Hinman (http://ethics.sandiego.edu)

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PRESENTATION OVERVIEW

• Outline of the course• What’s (bio)ethics?• What is an ‘ethical issue’?• How do we take our ethical decision?• Schools of thought in Bioethics

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OVERVIEW OF TODAY’S SESSION

• Introductions• Course objectives, learning methods and overview• Assignments• Ethics and Bioethics: Definitions & Context• Ethical Theories: Purposes and Approaches• Persons and Personhood• Facts and Values

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COURSE OBJECTIVES

• To consider critically a range of conceptual and ethical issues that we (as individuals and societies) face in health care provision.

• To analyze these issues using ethical frameworks, and to assess the value of such frameworks.

• To provide an opportunity to reflect critically on, challenge, develop and refine our ethical positions on particular issues.

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LEARNING METHODS

• Majority of learning done independently (readings, reflections, assignments)

• Course director facilitates learning in class and by appointment

• Classes: mix of short presentations, small and large group discussions, problem/case-based learning, student seminars

• Learn from each other’s experiences, perspectives, arguments, etc.

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LEARNING OBJECTIVES:

• to understand the role of ethical principles, theories and frameworks in bioethics

• to explore the concept of personhood• to understand the “fact/value” distinction• to understand and critically assess utilitarian ethical

frameworks• to understand the key concepts of principlism• to understand and critically assess Kantian ethical theory

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• to understand and critically assess Kantian ethical theory • to explore the notion of “relational autonomy” • to understand and critically assess social contract theory• to understand the key concept of justice• to understand how different conceptions of justice grow out

of different ethical frameworks• to discuss some concrete problems of resource allocation

and priority setting in health contexts

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• to understand and critically assess feminist bioethics• to consider the usefulness of the different ethical

frameworks for health care and research• to consider the potential of developing a “global bioethics” • to consider cultural, religious and spiritual aspects of ethical

decision-making• to understand and critically assess Islamic ethics and

Christian ethics

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COURSE EVALUATION

• Written ‘publishable’ paper (1500-4000 words) (60%) – due 20 January 2010

• Seminar co-presentation (40%) – during the course of the module (inclusive)

“Plan B”: MCQs and short notes (according to the JPCMFM regulations)

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ISSUE OF ETHICAL CONCERN IN PUBLIC HEALTH

Why ethics in public health?

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LET’S GIVE IT A THOUGHT!

• Within its efforts to control the spread of Pandemic Influenza A H1N1 during the Hajj season, the government was able to provide a total of 3,000,000 doses of the newly produced vaccine.

• The pilgrims are estimated to be 3,500,000; the working staff who are in contact with pilgrims (entries, security & health) are about 120,000 persons

• Who should have the vaccine?

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Figure 10.1 Changes leading to altered interaction between microbes, animals, and plants

Genetic changes in microbes, plants,

animals and humans

Social change in human populations - in material

circumstances, and behavior

Human interventions,

discoveries and manipulations of the environment

Natural environmental

change

Influence onindividuals and

families- varies by place

Over time population differences host, agent or environment factors

Population variations in health and disease patterns

Analysis and interpretation of differences to gain insight into the evolution of these patterns, and hence the causes

Demonstrate population differences in disease rates by time, place and person/population

Use information to improve health

The phenomena underlying population variations

Epidemiology tries to understand above phenomena

DIFFICULTIES FACING PUBLIC HEALTH PRACTICE• Scarcity of resources• Access to health services• Lack of trained personnel • Poverty, illiteracy , legal status• Role of local beliefs• Role of families and communities (leaders).

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LEVELS OF MORAL RESPONSE

• The expressive level (unanalyzed expressions or feeling that, by themselves, don’t provide reasons or justification)

• The pre-reflective level (justification via law, religious tenets, social values, codes of ethics, etc.; accepted uncritically)

• The reflective level (reasoned ethical argument/defence based on ethical principles, rules, virtues, values to which we consciously subscribe; justification provided)

Thomas J and Waluchow W, 1998

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MORAL, OR MORALITY

• Pertaining to or concerned with the principles or rules of right conduct or the distinction between right and wrong

• Morality is social obligation

11/6/2008

Ethical Issues In Community and Rural Health Care

MORAL DILEMMA

• An agent morally ought to do A, and ought to do Y, but is precluded by circumstances from doing both

• If A is done it is desirable in some respects and not desirable in other respects

• Moral reasons are weighty on both fronts but not dominant

11/6/2008


ETHICS

• explicit critical reflection on moral beliefs, practices and problems

• philosophical study of morality

This is at the reflective level…

(contrast with “descriptive ethics”)

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WHAT IS ETHICS?

• A system of moral principles • The rule of conduct recognized in respect to

particular society or human actions• Way of examining moral life• Moral reasoning of actions

11/6/2008


AN ISSUE IS AN ETHICAL ISSUE WHEN…

…we encounter conflicting values, beliefs, goals, or responsibilities…we are concerned that persons or their rights are not being respected…we are concerned about fairness and justice…we are unsure what we should do or why we should do it, morally speaking

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BRANCHES OF ETHICS

• metaethics• general normative ethics

o “applied” or practical ethics bioethics legal ethics business ethics environmental ethics organizational ethics …

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BIOETHICS

Bioethics involves critical reflection on moral problems faced in health care and research settings toward:

o deciding what we should do (what decisions are morally right or acceptable);

o explaining why we should do it (how do we justify our decision in moral terms); and

o describing how we should do it (the method or manner of our response when we act on our decision).

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WHAT IS BIOETHICS?

• Bioethics is about the study of ethical issues arising along health care or research, and the associated decision-making process to resolve them.

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BIOETHICS Ghaiath


• The study of ethical issues raised by public health interventions

WHEN DOES AN ISSUE IN PRACTICE BE AN ETHICAL ISSUE? (MODIFIED FROM

BARBARA SECKER AND FRANK WAGNER)

• When there is conflict of moral values, beliefs, and objectives e.g. between the health care providers and the patients.

• When there is conflict of commitments and responsibilities: e.g. saving patients' lives vs. using the available resources "rationally"

• When there is the concern that our patients rights/values are not respected.

• When the issue in focus is related to justice in allocating the available resources

• Finally, when we, as care providers feel that we are not sure what we should do.

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ETHICAL JUSTIFICATION

In ethics, the support/reasons ultimately come from moral values, principles and theories:• “I think we should do X because A and B are really

important values”• “Y wouldn’t be appropriate because it violates

principles A and B”• “X would be the right thing to do because of our

obligation to do A”

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Jonathan Breslin, 2006


Ethical theories and principles as lenses:“Doing bioethics well requires appeal to the insights provided by multiple theories…the metaphor of lenses provides a more accurate and a more productive understanding of the role of theories in bioethics…”

(Sherwin, The Politics of Women’s Health, 205).

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ON WHAT BASIS DO WE MAKE MORAL DECISIONS WITH OUR CLIENTS?

• “Do what the Bible tells you”--Divine Command Theories• “Follow your conscience”--The Ethics of Conscience• “Watch out for #1”--Ethical Egoism• “Do the right thing”--The Ethics of Duty• “Don't dis' me”--The Ethics of Respect • “...all Men are created ...with certain unalienable

Rights”--The Ethics of Rights• “Make the world a better place”--Utilitarianism• “Daddy, that’s not fair”--The Ethics of Justice• “Be a good person”--Virtue Ethics

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"DO WHAT THE QURAN/BIBLE TELLS YOU”DIVINE COMMAND THEORIES

• Being good is equivalent to doing whatever the Bible--or the Qur’an or some other sacred text or source of revelation--tells you to do.

• “What is right” equals “What God tells me to do.”

GhaiathEthics in Public Health (JPCMFM) Jan.2010

“FOLLOW YOUR CONSCIENCE”THE ETHICS OF OUR INNER VOICE

• Conscience tells us what is right or wrong• Often has a religious source• May be founded in a notion of human nature• Is often negative in character, telling us what is not right

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"WATCH OUT FOR #1”ETHICAL EGOISM

• Says the only person to look out for is yourself

• Ayn Rand, The Ethics of Selfishness

• Well known for her novel, especially Atlas Shrugged


"DO THE RIGHT THING"THE ETHICS OF DUTY

• Begins with the conviction that ethics is about doing what is right, about doing your duty.

• Duty may be determined by:o Reason

Kant: Do what any rational agent should do

o Professional role A physician’s duty to

care for the sicko Social role

A parent’s duty to care for his or her children


DEONTOLOGICAL ETHICS(DUTY-BASED ETHICS)

• Some say consequences are morally irrelevant• Others say consequences are morally relevant but

by themselves don’t determine the ethical nature of action

• Focus: rights and duties; permissible vs. mandatory actions

• Key questions: Are we treating cases similar in all morally relevant respects alike? Are we respecting persons?

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"DON'T DIS' ME"THE ETHICS OF RESPECT

• Human interactions should be governed by rules of respect

• What counts as respect can vary from one culture to anothero Examples:

spitting in the sand showing the soles of one’s shoes--Richardson

• What is it that merits respect?

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“...ALL MEN ARE CREATED ...WITH CERTAIN UNALIENABLE RIGHTS”THE ETHICS OF RIGHTS

• The most influential moral notion of the past two centuries

• Established minimal conditions of human decency


“MAKE THE WORLD A BETTER PLACE”UTILITARIANISM

• Seeks to reduce suffering and increase pleasure or happiness

• Demands a high degree of self-sacrifice—we must consider the consequencs for everyone.

• Utilitarians claim the purpose of morality is to make the world a better place.


UTILITARIANISM(CONSEQUENCE-BASED ETHICS)

• Actions not morally right in themselves—they become morally right if they produce certain consequences

• Focus: producing good consequences• Utilitarianism is a popular consequence-based

theory often appealed to in bioethics• Key question: will this action produce the greatest

overall amount of good (or the least overall harm) for the greatest number?

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“DADDY, THAT’S NOT FAIR”THE ETHICS OF JUSTICE

• Begins early in the family with fairness to all family members

• What is fair for one should be fair for all.

• Treating people equally may not mean treating them the same.


"BE A GOOD PERSON”VIRTUE ETHICS

• Seeks to develop individual character

• Assumes good persons will make good decisions

• Developed by Plato and Aristotle

• Integral to the Jesuit traditiono The Spiritual Exercises

• Provides a way of integrating all the theories


VIRTUE-BASED ETHICS

• Emphasizes moral character—not just moral action• Focus: not simply to act morally

but to be moral• Key questions:

o what kind of life should I live?o what kind of person should I be?


PRINCIPLISM

Framework includes four clusters of moral principles for identifying and reflecting on moral problems:• Respect for autonomy (self-determination or self-

governance)• Non-maleficence (avoiding harm) • Beneficence (doing good)• Justice (treat people and groups fairly, including

distributing resources fairly)

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FEMINIST ETHICS

• oppression (of all people, in all its forms) is morally and politically unjust and must be addressed

• social justice requires distributive justice plus fair relationships among social groups

• the self is essentially a “self-in-relation”• autonomy should be a relational (rather than an

individualistic) notion

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CLASSROOM APPLICATION

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FACTS & VALUES

WHAT ARE YOUR THOUGHTS ON:

“He killed her.”

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“Treatment is futile.”

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FACTS, VALUES AND CENTRAL CONCEPTS Ghaiath


• health• disease• disability• death• suffering• harm• benefit• best interests• quality of life• decision-making capacity• person

• definition(s)?• purely descriptive? value-

laden?• ethical significance?

THE FACT-VALUE DISTINCTION

• fact: description of the way the world is; an actual state of affairs (“is”)

• value: judgment about the way things should be (“ought”)

• no “ought” can be deduced from an “is”

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THE FACT-VALUE DISTINCTION Ghaiath


• “Clearly we ought not perform this surgery since there is only a 1% chance of survival. This treatment would be medically futile.”

• “The patient scored only 10/30 on the MMSE so we should get consent from the substitute decision-maker.”

the inferential leap

THE FACT-VALUE DISTINCTION

Science is the century-old endeavour to bring together by means of systematic thought the perceptible phenomena of this world into as thorough-going an association as possible. To put it boldly, it is the attempt at a posteriori reconstruction of existence by the process of conceptualisation. Science can only ascertain what is, but not what should be, and outside of its domain value judgements of all kinds remain necessary.-- Albert Einstein

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PERSONS AND PERSONHOOD

YOUR THOUGHTS/INTUITIONS…

• What/who is a “person”?


PERSONS AND PERSONHOOD

• “Personhood”: philosophical concept that attempts to capture the most basic properties of who persons are

• “Person”: one who has these most basic properties• Ethical implications: many think persons ought to be

treated better than nonpersons; many think persons have rights and nonpersons do not

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“Human being” is a biological term that refers to homo sapiens…

WHAT IS A PERSON?

Some proposals:• “Persons” are individuals who have a sense of self,

the ability to reason, possess—or are in the process of developing—a set of stable values and beliefs

• “Persons” are individuals who are “the subject of a life,” an on-going narrative

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PROPOSED CRITERIA FOR PERSONHOOD (FROM T.I. WHITE, 1991) Ghaiath


• alive• aware• + and - sensations• self-consciousness• controls own behaviour• recognizes other people

and treats them appropriately

• capable of analytical, conceptual thought

• able to learn• can solve complicated

problems with analytical thought

• capacity for communication that suggests thought

“HUMAN” VS. “PERSON”


humans personshumanpersons

FURRY PERSONS (?)


Matti

Hali

Fellini

WHO COUNTS AS A “PERSON”?

• human embryos? fetuses? infants?• non-human animals? (some? all?)• humans in PVS? coma?• humans with severe cognitive disabilities?

advanced dementia? • “extraterrestrials”?• other?

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“MORAL AGENT”

• “Anyone responsible for the outcome of her or his actions in a specific situation”

• “Agency requires that a person be able to understand the situation and be free to act voluntarily on her or his best judgment”

• Agency “implies that the person intends for something to happen as a result of that action”

(Ruth Purtilo)

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“MORAL PATIENT”

• “Moral patients” are worthy of ethical regard because they have interests (i.e., they can be harmed or benefited) but cannot be held morally accountable for their actions (e.g., infants, human beings with severe mental disabilities, or animals)

(Tom Regan)

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ETHICAL THEORIESPURPOSES AND APPROACHES

ETHICAL REASONING AND JUSTIFICATION

Requires:• moral awareness & imagination• knowledge• critical reflection• practical reasoning

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What actions are ethically justifiable? Why?What character traits are ethically desirable? Why?

CORE KNOWLEDGE

• How do we help reason through an ethical issue?• What counts as an ethical justification of a decision

or action? How do we argue for and defend our ethical claims?

• Are there any tools that can help guide us?

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ETHICAL REASONING

Values and ethical principles• Value = something a person/community has

identified as important (e.g., autonomy/self-determination)

• Values by themselves don't tell us what we ought to do

• Key values in bioethics have corresponding ethical principles meant to guide action (e.g., principle of respect for autonomy)

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ETHICAL REASONING

Critical reflection

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To give careful consideration

To question assumptions, both our own and others’

Critical reflection is important to avoid knee-jerk emotional responses and “jumping to conclusions,” as well as failing to

take other perspectives into account…


“Ethics focuses on the reasons why an action is considered right or wrong. It asks people to justify their positions and beliefs by rational arguments that can persuade others.”

-- Bernard Lo. Resolving Ethical Dilemmas, 3rd ed. (2005)

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Practical reasoning• The ability to reach a well-supported [i.e., well-

reasoned] answer to a well-defined question (Stanford Encyclopedia of Philosophy)

• The idea of the well-supported answer simply means being able to provide good reasons for the conclusion you reach or the opinion you hold.

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In ethics, the support/reasons ultimately come from moral values, principles and theories:• “I think we should do X because A and B are really

important values”• “Y wouldn’t be appropriate because it violates

principles A and B”• “X would be the right thing to do because of our

obligation to do A”

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APPROACHES TO ETHICAL REASONING

• deductive approach

• inductive approach

• reflective equilibrium or coherence theory ethical theory judgments in particular cases

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• There is no universally accepted ethical theory or top-ranked principle

• …but that’s ok/understandable…• Different theories and principles illuminate

different concerns that can serve as points of reflection

• Frameworks—or lenses—with which to reflect and attempt to resolve problems


NOW WHAT??


Ethical theories and principles as lenses:“Doing bioethics well requires appeal to the insights provided by multiple theories…the metaphor of lenses provides a more accurate and a more productive understanding of the role of theories in bioethics…”

(Sherwin, The Politics of Women’s Health, 205).

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ETHICAL THEORIES, PRINCIPLES AND FRAMEWORKS

• help identify, explore, clarify the ethical questions/issues

• help analyze and assess basic underlying assumptions

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ETHICAL THEORIES, PRINCIPLES AND FRAMEWORKS

• help develop, justify and criticize arguments, decisions, recommendations, policies, etc.

• help identify where arguments go wrong (your own and those of others) by exposing gaps, fallacies, inconsistencies, and/or unexpected consequences

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OVERVIEW ON ETHICAL THEORIES

• Utilitarianism • Deontology• Principlism• Virtue Ethics• Feminist Ethics• Casuistry• Religious Ethics (Islamic & Christian)

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UTILITARIANISM

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BASIC INSIGHTS OF UTILITARIANISM

• The purpose of morality is to make the world a better place.

• Morality is about producing good consequences, not having good intentions

• We should do whatever will bring the most benefit (i.e., intrinsic value) to all of humanity.

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THE PURPOSE OF MORALITY

• The utilitarian has a very simple answer to the question of why morality exists at all:o The purpose of morality is to guide people’s actions in such

a way as to produce a better world.• Consequently, the emphasis in utilitarianism is on

consequences, not intentions.

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FUNDAMENTAL IMPERATIVE

• The fundamental imperative of utilitarianism is: Always act in the way that will produce the greatest

overall amount of good in the world.o The emphasis is clearly on consequences, not

intentions.

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THE EMPHASIS ON THE OVERALL GOOD

• We often speak of “utilitarian” solutions in a disparaging tone, but in fact utilitarianism is a demanding moral position that often asks us to put aside self-interest for the sake of the whole.

• Utilitarianism is a morally demanding position for two reasons:o It always asks us to do the most, to maximize utility, not to

do the minimum.o It asks us to set aside personal interest.

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THE DREAM OF UTILITARIANISM:BRINGING SCIENTIFIC CERTAINTY TO ETHICS

• Utilitarianism offers us a powerful vision of the moral life, one that promises to reduce or eliminate moral disagreement.o If we can agree that the purpose of morality is to make

the world a better place; ando If we can scientifically assess various possible courses

of action to determine which will have the greatest positive effect on the world; then

o We can provide a scientific answer to the question of what we ought to do.

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INTRINSIC VALUE

• Many things have instrumental value, that is, they have value as means to an end.

• However, there must be some things which are not merely instrumental, but have value in themselves. This is what we call intrinsic value.

• What has intrinsic value? Four principal candidates:o Pleasure

Jeremy Benthamo Happiness

John Stuart Millo Ideals

G. E. Mooreo Preferences

Kenneth Arrow

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ACT AND RULE UTILITARIANISM

• Act utilitarianismo Looks at the consequences of each individual act and

calculate utility each time the act is performed.• Rule utilitarianism

o Looks at the consequences of having everyone follow a particular rule and calculates the overall utility of accepting or rejecting the rule.

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AN EXAMPLE

• Imagine the following scenario. A prominent and much-loved leader has been rushed to the hospital, grievously wounded by an assassin’s bullet. He needs a heart and lung transplant immediately to survive. No suitable donors are available, but there is a homeless person in the emergency room who is being kept alive on a respirator, who probably has only a few days to live, and who is a perfect donor. Without the transplant, the leader will die; the homeless person will die in a few days anyway. Security at the hospital is very well controlled. The transplant team could hasten the death of the homeless person and carry out the transplant without the public ever knowing that they killed the homeless person for his organs. What should they do?o For rule utilitarians, this is an easy choice. No one could approve a general

rule that lets hospitals kill patients for their organs when they are going to die anyway. The consequences of adopting such a general rule would be highly negative and would certainly undermine public trust in the medical establishment.

o For act utilitarians, the situation is more complex. If secrecy were guaranteed, the overall consequences might be such that in this particular instance greater utility is produced by hastening the death of the homeless person and using his organs for the transplant.

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CRITICISMS OF UTILITARIANISM

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1. Responsibility2. Integrity3. Intentions4. Moral Luck5. Who does the calculating?6. Who is included?

DEONTOLOGY

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THE ETHICS OF DUTY

More than any other philosopher, Kant emphasized the way in which the moral life was centered on duty.


DEONTOLOGICAL ETHICS(DUTY-BASED ETHICS)

• Some say consequences are morally irrelevant• Others say consequences are morally relevant but

by themselves don’t determine the ethical nature of action

• Focus: rights and duties; permissible vs. mandatory actions

• Key questions: Are we treating cases similar in all morally relevant respects alike? Are we respecting persons?

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UNIVERSALIZABILITY AND THE CATEGORICAL IMPERATIVE

Central insight:• What is fair for one is fair for all

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LIVING BY RULES

• Most of us live by rules much of the time. Some of these are what Kant called Categorical Imperatives—unconditional commands that are binding on everyone at all times.

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TYPES OF IMPERATIVES

• Hypothetical Imperative:o “If you want to drive to Medani from Khartoum, take the

Medani ‘highway’.”o Structure: if…then…

• Categorical Imperativeo “Always tell the truth”o Unconditional, applicable at all times

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MAXIMS

• Maxims, according to Kant, are subjective rules that guide action. o Relevant Act Descriptiono Sufficient Generality

• All actions have maxims, such as, o Never lie to your friends.o Never act in a way that would make your parents ashamed

of you.o Always watch out for number one.o It’s ok to cheat if you need to.

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CATEGORICAL IMPERATIVES:• Universality:• “Always act in such a way that the maxim of your action can be

willed as a universal law of humanity.”• Respect• “Always treat humanity, whether in yourself or in other people,

as an end in itself and never as a mere means.”--Immanuel Kant

• Publicity:• Always act in such a way that you would not be embarrassed to

have your actions described on the front page of The New York Times.

--Probably not Bill Clinton

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CATEGORICAL IMPERATIVE: Ghaiath


CATEGORICAL IMPERATIVES:ANOTHER EXAMPLE

• “I know the questions to ask. It’s the answers I’m after. And what about learning how to live? Isn’t that philosophy too? What’s yours?”

• The reply had come easily but, she had thought, with honesty. “To get as much happiness as I can. Not to harm others. Not to whine. In that order.”

Adam Dalgliesh, in reply to Kate Miskin’s questionP. D. James, A Certain Justice

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CLASSROOM EXERCISES

• Most of us live by rules, obedience to which we take as a duty.o What are the most important rules you live by?o What were the most important rules in your family?o What rules have you rejected as you have gotten older?

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WHERE KANT MISSED THE MARK

• The Neglect of Moral Integrationo The person of duty can have deep and conflicting

inclinations and this does not decrease moral worth—indeed, it seems to increase it in Kant’s eyes.

• The Role of Emotionso For Kant, the emotions are always suspect because they

are fickle and causally determined and passive.• The Place of Consequences in the Moral Life

o In order to protect the moral life from the vicissitude of moral luck, Kant held a very strong position that refused to attach moral blame to individuals who were acting with good will, even though some indirect bad consequences could be forseen.

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PRINCIPLISM

Framework includes four clusters of moral principles for identifying and reflecting on moral problems:• Respect for autonomy (self-determination or self-

governance)• Promote non-maleficence (avoiding harm) • Promote beneficence (doing good)• Promote justice (treat people and groups fairly,

including distributing resources fairly)

Ghaiath


VIRTUE-BASED ETHICS

• Emphasizes moral character—not just moral action• Focus: not simply to act morally

but to be moral• Key questions:

o what kind of life should I live?o what kind of person should I be?


FEMINIST ETHICS

• oppression (of all people, in all its forms) is morally and politically unjust and must be addressed

• social justice requires distributive justice plus fair relationships among social groups

• the self is essentially a “self-in-relation”• autonomy should be a relational (rather than an

individualistic) notion

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CASUISTRY (CASE-BASED REASONING)

• “bottom-up approach”• case comparison/analogy used toward ethical

consensus• practical judgment in particular cases with appeal

to precedent (“paradigm cases”) where possible

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CASUISTRY: ASSESSMENT

Strengths:• contextual approach recognizes each case is

uniqueLimitations:• conflicting case analogies, judgments,

interpretations• facts of case themselves can’t yield ethical

judgments• appeal to precedent assumes we got it right in the

past—how do we know?• no method to prevent biased account of case or

one that neglects relevant features• “lacks critical distance from cultural blindness, rash

analogy, and mere popular opinion” (B&C 395)

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publicHealthEthics-course_Outline&Introduction