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Chapter 1
Theory of Health Care
Ethics
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Why Study Ethics?
• Because health care is changing, you need
tools for making necessary and difficult
decisions.
• It will help you better understand patients,
fellow professionals, and the system in
general.
• It will assist you in building and maintaining
your career.
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Types of Ethics
• Normative ethics
– Is the study of what is right and wrong.
• Metaethics
– Is the study of ethical concepts and theories.
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Types of Normative Ethical Theories
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Authority-based
Egoistic
Natural law
Deontological
Teleological
Virtue
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Ethical Relativism
• Ethical relativism purports that there is no
absolute theory for ethics.
• However, this lack of a complete theory does
not mean everything is relative.
• People need to make rational decisions about
ethics-based issues.
• Therefore, ethics theories are useful.
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Egoism as Ethics Theory
• Egoism is based on the idea that one’s self
interest is the basis his or her ethics decisions.
• Theory is not helpful in health care ethics
because professionals are taught to set aside
self-interest.
• The interests of the patient should come first.
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Authority-based Ethics Theory
• Decisions about ethics (right or wrong) are
based on central authority such as in a
theology or an ideology.
• For health care ethics, there may difficulty
deciding which authority is the correct one.
• However, knowing this view of ethics helps
with understanding patients and health policy
decisions.
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Virtue Ethics Theory
• Is founded in the writings of Aristotle.
• Everything moves from potentiality to
actuality.
• Character development allows you to
actualize your highest good.
• Eudaimonia should be sought as the highest
good.
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Virtue Ethics Theory
• Eudaimonia means that you seek to build your
character and increase virtue.
• Professional education seeks to develop
people of high character.
• People who work toward eudaimonia become
persons of practical wisdom.
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Virtue Ethics Theory
• Principles of ethics can help to define your
character and assist with your actions. See
Chapter Two for more information.
• Virtue ethics is criticized as being elitist.
• Virtue ethics requires the balancing of
conflicting obligations.
• People with practical wisdom can make
appropriate ethical decisions.
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Natural Law Theory
• It is founded in the writings of St. Thomas
Aquinas
• It assumes that nature is rational and orderly.
• Humans are part of the natural world and are
given the ability to be rational.
• Our natural reason allows us to distinguish
right from wrong.
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Natural Law Theory
• Reason is also action in that humans can
choose to do good or evil.
• The Principle of Double Effect helps us
decided which action is good.
• Good is also defined as that which helps to
maximize potential, such as preserving life,
gaining wisdom, and knowing God.
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Natural Law Theory
• In natural law, there are some acts that are
not ethical because they violate the ability to
reach one’s potential.
• People who support social responsibility can
use natural law as a foundation for actions.
• Understanding natural law also assists with
patient relations.
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Deontology Theory
• Comes from the Greek word “deon” meaning
“duty.”
• It is sometimes called duty-based ethics.
• One of the main theorists is Immanuel Kant.
• The world exists in the form of things we can
experience directly (phenomenal world) and
things that exist independently of the intellect
(noumenal world).
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Deontology Theory
• Free will makes ethics possible and without it
we would not need ethics.
• Areas of character can be used for good or
evil.
• Therefore, the only true good is good will.
• The ability to choose to do good is what
makes us human.
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Deontology Theory
• Actions are judged by their intention and not
just their outcomes.
• Kant attempted to define a rational principle
for making moral judgments.
• The principle is the categorical imperative.
• People can never be used as a means to an
end; they must be respected.
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Deontology Theory
• The Golden Rule is not a synonym for the
categorical imperative.
• Kant believed that we must act based on duty
to moral law and not on the consequences of
our actions.
• Practicing this is its pure form is difficult in
modern society.
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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
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Deontology and Policy
• Health care professionals recognize a duty to
the patient
• Health care managers also have a duty to the
patient, but they have duties to the
organization and community as well.
• Conflicting duties must be considered in policy
making.
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Non-Kantian Deontology
• Recent proponents of the deontology
tradition include John Rawls and Robert
Nozick.
• These theorists deal with the idea of justice
through our actions.
• Their thinking influences health care reform,
public health, and other health areas.
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John Rawls
• John Rawls worked to define the
characteristics of a just society.
• He examined justice as fairness and applied it
to societies that respect the rule of law.
• His work is based on the idea of a social
contract between members of a society.
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Self Interest and Justice
• Rawls used a hypothetical or mind experiment
called the original position to explain why
rational people would protect everyone’s self
interests.
• In this mind experiment, he also included the
concept of the veil of ignorance to help us
understand why we would care about self
interests.
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Self Interest and Justice
• If we were in the original position, we would
all be equal.
• Therefore, we could all be treated in the same
way in a society.
• Therefore, it would be in our self interest to
make sure that everyone is given an equal
share of benefits and burdens.
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Basic Principles of Justice
• The first principle of justice for Rawls is liberty.
• This principle is also a priority over all other
principles of justice.
• People should have equal right to basic
liberties (see the Bill of Rights).
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Basic Principles of Justice
• The second principle for Rawls is justification
of inequalities.
• He uses the difference principle to justify
when social and economic inequities are
appropriate.
• Physicians are a classic example of the
difference principle.
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Rawls’ Opponent
• Robert Nozick is also considered to be a
deontologist.
• He represents the conservative tradition and
has great influence in the debate over health
care reform.
• Nozick emphasizes the autonomy and the
rights of the individual.
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Nozick and Social Goods
• For Nozick, there is no social good that
requires sacrifice.
• We are only “other people”.
• We should influence people to take steps to
improve their own situations.
• Theories like Rawls supports defeat voluntary
agreements.
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Nozick and Distributive Justice
• For Nozick, there is no principle of distributive
justice.
• He finds justice in acquisition and owned
resources.
• Historical injustices are not addressed in his
theory except to suggest that society could be
organized to maximize the position of the
least well off.
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Consequentialism Theory
• Through Mill’s work, this theory is also known
as utilitarianism.
• For this theory, your intentions are irrelevant;
all that counts is the outcome.
• Greatest Good for the Greatest Number is
often used as a summary of the theory.
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Consequentialism Theory
• Has two main types
• Classical or act utilitarianism.
– Each act considered on its own
• Rule utilitarianism.
– Develop rules that net the greatest benefit
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Consequentialism Theory
• Rule utilitarianism is used to make health care
policy.
• Exceptions can be made under special
circumstances.
• Rule utilitarianism also allows for negative
consequentialism or preventing the greatest
harm for the greatest number.
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Consequentialism Theory
• Preference utilitarianism argues that good is
honoring preferences and bad is frustrating
preferences
• Preferences must be known or a substituted
judgment can be used
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Consequentialism Theory
• Criticisms of utilitarianism include
– The minority is not protected when the
greatest good for the greatest number is
the goal.
– Some say this theory means that the ends
justifies the means.
• These criticisms are not valid because respect
for autonomy and liberty is essential to the
theory.
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Use of Ethical Theories
• There is no pure ethical theory; each has
strengths and weaknesses.
• However, health care professionals must make
complicated ethics decisions
• The ability to understand theory enhances
your decision making tool kit.
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In Summary…
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1
Chapter 2
Principles of Health Care
Ethics
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Principles of Ethics
• Extends your foundation of ethics.
• Gives you ways to apply ethics to practical
situations.
• The four most often used in health care are
nonmaleficience, beneficence, autonomy, and
justice.
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Nonmaleficience
• Sometimes this is translated as “first do no
harm”.
• Ethical theories define harm in different ways.
• Consequentialist says harm is that which
prevents good.
• Natural law says harm is something that limits
our potential.
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Nonmaleficence
• Deontologists say harm is something that
prevents you from doing your moral duty.
• Virtue ethicists say harm is something that
leads you away from practicing high moral
character.
• Ethical egoists say that harm is something that
goes against your self interest.
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Harm in the Clinical Setting
• Harm is something that negatively affects
patients.
• Clinically, we think of physical harm but other
harm is possible.
• Harm is also caused by negligence.
• Harm can be caused by violating autonomy.
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Beneficience
• Beneficence comes from the Latin word for
good- “bene”- and means to benefit.
• Requires a decision to engage in beneficent
acts or to be altruistic.
• It is a fundamental principle of health care
practice.
• What theories support beneficence?
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Health care and Beneficience
• The standard of altruism is higher for health
care professionals.
• Altruism is expected.
• Beneficence sometimes is extended to
paternalism when the health care professional
makes decisions for the good of the patient.
• What is this called?
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Autonomy
• Autonomy means that you can rule yourself.
• It implies a respect for others.
• In health care, we have a duty to treat, but not
to judge.
• What are the conditions necessary for
autonomy in health care?
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Specific Competence
• Is defined as the ability to do some things but
not others. So, you can be competent in a
limited way.
• In issues where a person is not competent, the
concept of substitute judgment can be used.
This is also involves the idea of reasonable
person’s decision.
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Specific Competence
• Coercion can also affect a person’s ability to
exercise autonomy.
• Issues of competence and autonomy also are
part of informed consent and other health
care issues which are discussed in later
chapters.
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Justice
• The term can be used to mean fairness.
• Aristotle thought we should treat similar cases
in a similar way unless there was some
relevant or material difference.
• We need to examine types of justice:
procedural and distributive.
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Procedural Justice
• This is sometimes called due process.
• It means that you get your turn; you are
treated like everyone else.
• Procedural injustice can occur with employee
situations.
• Due process is also involved with policy
making in procedural justice.
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Distributive Justice
• This form of justice involves balancing benefits
and burdens.
• Health care resource allocation is one example
of an distributive injustice?
• Health care is a scarce resource, so
• Resource allocation issues are common in
health care; what are some examples of these
issues?
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Material Reasons to Discriminate
• Basic argument is that the person deserves it
or needs it
• In the U.S., if you work hard, you deserve to
be rewarded.
• In contrast, if you disobey the law, you
deserve to be punished.
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Discrimination based on Need
• Need can be based on misfortune or disability.
• Need can be based on special talents or
abilities and on opportunities.
• Need can be based on past discrimination.
• Need can also be based on structural social
problems.
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In the larger society…
• There is a need to discriminate based on
material need.
• You are rewarded based on how much you
contribute.
• You are also rewarded based on how much
effort you put forth.
• This thinking also applies to patient care. Can
you give some examples?
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Need based on Misfortune
• Misfortune can lead to discriminate based on
or against need for care.
• For example, life threatening situations are
treated before minor emergencies.
• Special talents or the potential loss of
opportunity can be arguments for special
treatment.
• What other groups fall into the need based
category?
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Need based on past Discrimination
• Redress of past injustices may be a reason for
different treatment.
• The health care system has responded to the
needs of some special groups.
• Structural problems have also been
considered in needs based discrimination;
what are some examples?
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Distributive Justice and Rights
• We are still debating if health care is a right or
a commodity.
• Need to think about whether something is a
legal right or a moral right.
• There are many types of right and many
overlap each other (See figure in text).
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Legal or Positive Rights
• Legal right means that someone has a legal
obligation to fulfill your right.
• Positive right means that you are entitled to
something.
• Sometimes legal rights become that which you
can enforce.
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Substantive Rights
• Can be legal rights or not.
• They are right to a particular thing such as
education, health care, minimum wage, etc.
• Different nations have differing opinions
about substantive rights for their citizens.
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Negative Rights
• You have the right to be left alone.
• The Bill of Rights lists many negative rights.
• The negative right of one person may be in
conflict with the negative right of another (i.e.
smokers).
• Other negative rights include freedom from
sexual harassment, and medical record
privacy.
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Process, Natural, and Ideal Rights
• You have the right of due process.
• Natural rights means that you respect the
attributes that people have in nature.
• These rights allow humans to reach their full
potential.
• Natural rights express our common morality
and ideal rights inspire.
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Reflective Equilibrium Model
• Making ethical decisions requires considered
judgments.
• These judgments require rational moral
reasoning.
• Ethical theories and principles are used to
explain moral reasoning.
• Reflective equilibrium model provides a
process for considering and reconsidering
decisions.
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Reflective Equilibrium Model
Considered
judgments
Common
morality
Health care issue
at hand
Ethical
principles
Ethical
theories
Reflective equilibrium at work
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How can you Use the Model in Practice?
• Describe a situation where making an ethics
choice might be difficult.
• Now, use Reflective Equilibrium Model to
assist you in deciding the most ethical decision
to make.
• Why is this model not in common practice in
health care?
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In Summary…
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Biomedical Ethics: Week 1
Critical Reflection Paper: Chapters 1 & 2
Objective: To critically replicate you’re thoughtful of the readings and your competence to rub
on them to your Health care ethics.
ASSIGNMENT GUIDELINES (10%):
Students will judgmentally appraise the readings from Chapter 1 and 2 on your textbook. This
assignment is intended to help you assessment, examination, and spread over the readings to
your healthcare ethics as well as become the foundation for all of your remaining assignments.
You need to read the article (in the additional weekly reading resources localize in the Syllabus
and also in the Lectures link) assigned for week 1 and develop a 2-3-page paper reflecting your
appreciative and ability to apply the readings to your ethics. Each paper must be typewritten with
12-point font and double-spaced with standard margins. Follow APA format when referring to
the selected articles and include a reference page.
EACH PAPER SHOULD INCLUDE THE FOLLOWING:
1. Introduction (25%) Provide a short-lived summary of the undertone (not a description) of
each Chapter and articles you read, in your own words.
2. Your Critique (50%)
What is your response to the content of the articles?
What did you absorb about the Types of Ethics? Mention and explain two examples where you
can apply them.
What did you obtain about the key features of the natural law?
What is Deontology Theory and its principles? Apply them your future carrier.
Mention and describe all the principle of ethics and mention example of them that apply to your
professional life.
3. Conclusion (15%)
Fleetingly recapitulate your thoughts & postulation to your analysis of the articles and Chapter
you read. How did these articles and Chapters impact your thoughts about the principles of
ethics?
Evaluation will be based on how clearly you respond to the above, in particular:
a) The clarity with which you critique the articles;
b) The depth, scope, and association of your paper; and,
c) Your conclusions, including a description of the impact of these articles and Chapters on any
Health Care Setting.
ASSIGNMENT DUE DATE:
The assignment is to be electronically posted in the Assignments Link on Blackboard no later
than noon on Sunday, June 30, 2019.
Originality: Turnitin submission required
ASSIGNMENT RUBRICS
Assignments Guidelines
Introduction
Your Critique
Conclusion
Total
1.0 Points
2.5 Points
5.0 Points
1.5 Points
10 points
10%
25%
50%
15%
100%
ASSIGNMENT GRADING SYSTEM
A
B+
B
C+
C
D
F
Dr. Gisela LLamas
90% – 100%
85% – 89%
80% – 84%
75% – 79%
70% – 74%
60% – 69%
50% – 59% Or less.
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Turnitin Report
Formatting
Title Page
Citation
Outline
