Part I: Foundations

Topic: The reflective equilibrium is an ethical decision-making model.  List three (3) ways that this model can assist you in making ethics-based decisions in health care settings. Do you find any of the other models mentioned useful?

Chapter Two Principles of Health Care Ethics Spring 2023 Compounding Effects of Ethics • Ethical choices at the individual level often permeate well beyond the scope of our individual realms. • This diagram also reflects how change (good or bad) occurs. Societal Organizational Clinical Professional Individual Principles of Ethics The four principles: • Provide context to the foundational theories • Assist to apply ethical decision making to situations • What is legal is not always right, but what is right is not always legal • Each principle is an obligation beneficence: to do good nonmaleficence: to do no harm autonomy: to permit an individual selfgovernance justice: to give to each his or her due Beneficence • The obligation • to do good • to take positive & direct steps to help others • The underlying principle of Consequentialism “greatest good for the greatest number” • Basis to see every patient as a unique person who has worth • The common morality & fundamental principle of healthcare • Altruism is expected • Expectation to act with beneficence in all daily activities Nonmaleficence • The obligation to do no harm • Qualified by the Rule of Double Effect • Harm • defined differently by the different theories • can have various shapes and sizes • is not simply physical • 2 types of harm 1. Omission – appropriate actions not taken to cause; negligence 2. Commission – actions taken to cause Harm as a Violation of Autonomy • Omission • Commission • Substituted Judgement decisions are made from discussion(s) with the person prior to becoming incompetent • Best interest / Reasonable person decision decisions are made for the incompetent person, without earlier discussions, based on what a reasonable person in that situation would choose Autonomy • The obligation to permit an individual self-governance • Implication of a respect for others • Prevents paternalism & paternalistic healthcare • Healthcare duty is to treat without judgement • 2 key autonomy conditions: • Is the patient competent to make their own decisions? • Is the patient free of coercion to make decisions? • Specific competence = the ability to do some things, but not others • Basis for informed consent Justice • The obligation to give each his or her due • equal share OR • according to need • according to effort • according to contribution • according to merit • 2 types: • Procedural justice • Distributive justice • Aristotle believed in treating similar cases alike except when there are relevant or material differences in the cases. Procedural Justice • Focus on procedures – existence of & adherence to • “Due process” • When you get your turn, you are treated like everyone else • Typically found in • employee relations • health policy hearings Distributive Justice • Focus on resource allocation, balancing benefits & burdens • Occurs at all levels of an organization • Examples: • standards of care • patient rounds • sequencing of COVID vaccines • salaries • provider schedules Material Reasons to Discriminate Two concepts: • the person deserves it because of one’s contribution or results & efforts • the person needs it because of • circumstances characterized as misfortune • mental or physical disabilities (unequal natural endowments) • special talents or abilities • opportunities they might have or lose • past discrimination perceived as negative effects on the present • structural social problems perceived as restricting opportunity or motivation • In the larger society, discrimination is based primarily on market contributions, results, & effort Discrimination Based on Need • Need based on misfortune • triage • disasters & emergencies • genetics • special talent • Need based on past discrimination • redress of past injustices • special health systems (Veterans Health Administration, Indian Health Service) • transportation, poverty, housing, education, language barriers Distributive Justice and Rights • Is healthcare a right or a privilege? • (the debate continues…) • Moral vs legal right • Many types of rights, some even share characteristics Legal and Positive Rights • Legal right = • someone has a moral obligation to fulfill your right • voting, not discriminated against • Positive right = • subset of legal rights • social “goods” • written into law… entitlement • education, due process Substantive Rights • May or may not be legal rights • Rights to a particular thing: • education • minimum wage • safe streets • clean environment • emergency medical care • welfare • Nations differ in their opinions about substantive rights for citizens Negative Rights • The right to do anything not strictly forbidden by the law • Examples: • live a life as we individually see fit • privacy (HIPAA) • protection from sexual harassment & hostile work environment • Negative rights may conflict among individuals • Bill of Rights lists many of these Process, Natural, and Ideal Rights • Process rights = • legal rights • right to due process • Natural rights = • respect for attributes humans have by nature • express our common morality • life, liberty, & pursuit of one’s full potential • Ideal rights = • statement of a right that is meant to be motivational, such as a goal to seek • guide organizations, communities, & nations to attain higher standards Reflective Equilibrium Decision-Making Model • A continual thought process for considering and reconsidering decisions • Considered judgements = • ethical intuitions (moral reasoning) • what individuals who make decisions about what to do use • requirement for ethical decisions • Require moral reasoning based on ethical theories & principles Beauchamp & Childress’ Ethical Decision-Making Model 1. Apply the principles: a. Respect for Autonomy b. Beneficence c. Nonmaleficence d. Justice 2. Specify the principles 3. Balance the principles 4. Decide Twadell-Soleri & McDermott’s Model for Making Ethical Decisions 1. Gather the facts 2. Determine the ethical issues 3. What norms/principles/values have bearing on this case? 4. List the alternatives 5. Compare the alternatives with the norms/principles/values 6. Weigh the consequences 7. Make a decision Weber, Leonard J. (2001) Business Ethics in Healthcare: Beyond Compliance. Indiana University Press. page 19 Conclusion • One has no rights if they are not legal rights • Ethical decision-making can be messy & errorprone • The process matters as much or more than the product • Ethics is not neutral Chapter One Theory of Health Care Ethics Spring 2023 2 Why Study Ethics? • Healthcare is consistently changing • Tools to make necessary and difficult decisions. • To better understand patients, fellow professionals, and the HC system in general. • To assist in building and maintaining your career. Types of Ethics Normative ethics: Metaethics: the study of what is right and wrong. the study of ethical concepts and theories. 3 Types of Normative Ethical Theories Egoistic Authoritybased Virtue Natural law Teleological Deontological 4 5 Ethical Relativism • Ethical relativism reasons that there is no absolute theory for ethics – “it’s all relative”. • However, this would mean there are no real right, wrong, good, or bad decisions & action. • Rational ethics-based decisions must still be made • These theories help to affect the health, well-being, and lives of patients. 6 Egoism as Ethics Theory • One’s self interest is the basis of one’s ethical decisions • Not helpful in healthcare ethics professionals are taught to set aside their self-interest. • The interests of the patient should come first – patientcentered care. 7 AuthorityBased Ethics Theory • Based on a central authority such as: • religion • tradition • elders of a culture • ideology (communism, capitalism, etc.) • Difficult to distinguish as normative, due to conflicting beliefs • Which authority is correct? • Helpful to understand patients & health policy 8 Virtue Ethics Theory (1/2) • Founded in the writings of Aristotle & Plato • Everything moves from potentiality to actuality • Asks, “what is the proper behavior?” • Character development leads to your highest good • Eudaimonia: • you seek to build your character and increase virtue. • should be sought in life • persons of practical wisdom develop from those who practice 9 Virtue Ethics Theory (2/2) • Professional education seeks to develop people of high character. • Principles of ethics can help to define your character and assist with your actions. • Criticized as being elitist • Requires balance of conflicting obligations. • People with practical wisdom should be better prepared to make ethical decisions. 10 Natural Law Theory (1/2) • Founded in the writings of St. Thomas Aquinas & believed by the Greeks • Assumes nature is rational and orderly in accordance with God’s wisdom • Humans are part of the natural world and are given the ability to be rational • Natural reason allows us to: • distinguish right from wrong • choose to do good or evil 11 Natural Law Theory (2/2) • A foundation for social responsibility & social justice movements • Social & political factors that prevent actualizing potential: • poverty • ignorance • unhealthy living conditions • human rights • public health 12 Principle of Double Effect • Helps us decide which action is good. • 4 key points : 1. act must be good, or morally neutral, independent of its consequences 2. agent intends only the good (not the bad) effect(s) 3. bad effect(s) is not a means to the good effect(s) 4. good effect(s) must outweigh the bad effect(s) • Good = that which helps to maximize potential (preserve life, gain wisdom, & know God) 13 Deontology Theory • Derives from the Greek word “deon” = duty • Also named duty-based ethics • Main theorists: • Immanuel Kant • John Rawls • Robert Nozick • Healthcare professionals & administrators have a duty to the patient • HC administrators also have duties to the organization & community • Policy addresses conflicting duties 14 Immanuel Kant • All experiences are subject to causation, which undermines free will • Free will is essential to & for ethics • Character attributes can be used for good or evil • The only true good is good will • The ability to choose is what makes us human • Actions: • are judged by their intention, not just their outcome(s) • must be based on duty to moral law, not the consequences • Practicing this in its pure form is difficult in modern society 15 Categorical Imperative • Kant’s rational principle for making moral judgments • Act in a way that your action could become a universal law • The Golden Rule is not a synonym • People are not a means to an end; they are the end (so should be respected) 16 Kant and Virtue Ethics • Pure Kantian ethics is absolute in its definition of duty, but virtue ethics allows for grey areas • Kant does not assist with deciding among lesser evils and greater goods • Virtue ethics allows the use of tools to make these decisions 17 NonKantian Deontology • Recent proponents • Deal with the idea of justice through our actions • Their thinking influences: • health care reform • public health • other health areas 18 John Rawls (1/2) • Worked to define the characteristics of a just society • “Justice as fairness” • His work is based on the idea of a social contract between members of a society • The Original Position – • explanation of why rational people would protect one’s self-interests • we would all be equal & could all be treated in the same way in a society • it would be in our self-interest to make sure everyone is given an equal share of benefits and burdens 19 John Rawls (2/2) • The Veil of Ignorance – explanation of why we care about self-interests • Basic Principles of Justice: • Liberty • priority over all other principles of justice • people should have equal right to basic liberties (Bill of Rights) • Inequalities • Difference Principle • used to justify when social & economic inequities are appropriate • inequities are used to help the lesser fortunate (physicians) 20 Robert Nozick (1/2) • Represents the conservative tradition • Great influence in the debate over health care reform • Emphasized autonomy & rights of the individual • “Individuals have rights, and there are things no person or group may do to them (without violating their rights).” • No social good requires sacrifice • Everyone should influence others to take steps to improve their own situations 21 Robert Nozick (2/2) • Does not believe in principle of distributive justice • Justice is in acquisition and owned resources • Historical injustices are not addressed, except to suggest that society could be organized to maximize the position of the least well off. 22 Teleological Theories • Derived from the Greek word “telos” = ends • Ethics of a decision are dependent on the consequences or effects of the action • Goal: the greatest good for the greatest number • 2 types: • Classical Utilitarianism • Rule Consequentialism • Consequentialism = Utilitarianism 23 Types of Teleological Theories • Classical Utilitarianism – each act is considered based on its net benefit • Rule Consequentialism – • the decision maker will develop rules that net the greatest benefit (health policy) • 2 Types: • Negative Consequentialism preventing the greatest harm for the greatest number • Preference Consequentialism – • good is honoring preferences and bad is frustrating preferences • Preferences must be known, or a substituted judgment can be used 24 Consequentialism Theory • Due to Jeremy Bentham & Stuart Mill’s, this theory is also known as utilitarianism • Your intentions are irrelevant; all that matters is the outcome • Criticisms of the theory: • the minority is not protected when the greatest good for the greatest number is the goal • this theory means that the ends justifies the means **these criticisms are invalid since respect for autonomy and liberty are essential to the theory 2 5 • There is no pure ethical theory; each has strengths and weaknesses Conclusion • Health care professionals must make complicated ethical decisions • The ability to understand theory enhances your decision-making tool kit

A Sample Answer For the Assignment: Part I: Foundations

Title:  Part I: Foundations