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?

3 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

4 Three Categories of Ethical Argument Consequences (outcomes):  Utilitarianism Rights (starting points):  Liberalism Virtues (character):  Communitarianism

5 Each Perspective Has Unresolved Issues How do we measure consequences? Which rights do citizens have? Who defines the community and its values?

6 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”

7 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

8 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

9 Subjective Utilitarian Ask consumers about their “willingness to pay” Use data about prevalence, costs, and prices to calculate costs and benefits

10 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?

11 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

12 biggest bang for the buck

13 Problems with Objective Utilitarianism Who determines the index? Accountability and transparency Technical decisions can mask value choices: Time Age of death Disability vs. death

14 General Problems with Utilitarianism Concerned with aggregate welfare not with distribution Lack of respect for individuals Can justify inequality Technical calculations can mask values

15 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

16 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

17 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

18 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

19 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?

20 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

21 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)

22 Problems for Relative Communitarians How do we know the boundaries of communities? How far can communities go to suppress dissent?

23 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?

24 Broader Question of Justification Faith Intuition Logic The World There is no justification

25 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

26 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

27 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

28 That’s all, folks!