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Ethical Issuesin Health
Research inDevelopingCountries
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The Place of Clinical
Bioethics in Health Careand Philosophy
Dan W. Brock
Harvard Medical School
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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 doesclinical bioethics need philosophy?
Often, there is no clear, uncontroversial answer
about what to do
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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 SystemExample: What is a fair system of health insurance?
IV Population-level Bioethics
Example: when are health inequalities unjust?
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Why Arent the Ethical Views YouAlready 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 ethicalissues, e.g. PAS
Some disagreement is about facts
But other disagreement is about moral permissibility
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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?
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Ethical Reasoning
How is it different from matters of taste?
For example, with taste (I like chocolate, you likevanilla) we think theres nothing more to be saidwe
just disagree and there is no correct taste
How are ethical questions different?
Some imply they arentwisdom of repugnance
But they areethical judgments/beliefs require
reasons.
A Why? is always appropriate.
Reasons will be general properties of actions, persons, etc.
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Example of Abortion
Sallys abortion was wrongWhy?
Because it is killingbut not all killing iswrong, 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?
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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 avoidbecoming pregnant
Thomsons violinistuse of hypothetical cases
This is a process of clarifying the reasons for
your moral judgments
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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
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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
Does this guarantee agreement?
No, some moral disagreement may be irresolvable
But, it does clarify precisely what the disagreement is
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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
Does this make your view justified?
Yes, it is what you hold after full consideration of all relevantreasons and arguments
So there is nothing left to consider
Made in relatively ideal conditions for judging
Is what youre prepared to judge yourself and others by
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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.
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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 arejudged by their different standards
So they are not disagreeing
Relativism is mistaken
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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 killedApplies to wide range of cases
Has other featuresrights can be waived, exercised,forfeited, etc
Rights make person small scale sovereign in area of theright
Focus on victim of rights violation
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Features of Moral Reasoning--Cont
Cf. different duty based account of wrongness of
killingalways wrong to deliberately take innocenthuman 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.
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How Should Your Hospital Distribute
Antiviralsin an Avian Flu Pandemic?
For the past several months, there has been sustained human-to-
human transmission of a novel strain of avian influenza A withgenetic components of human influenza in several countriesaround the world. Your community was first affected three weeksago, and since then there have been over 500 cases and 50deaths. Oseltamivir phosphate is the only drug that may effectivelyreduce mortality of ill patients and limit infection of exposed
persons. However, supplies of oseltamivir are limited, andhospitals across the country are independently making decisionsto govern allocation of antivirals within their institutions. In yourcommunity, the four major academic medical centers haverecently established four different protocols regarding prioritizationof access to care:
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Hospital A
Recognizing the importance of protecting its
workforce in order to minimize absenteeismand ensure continuous response capacity,
Hospital A has decided to use its remaining
cache of oseltamivir forprophylaxis of staff
who are exposed while caring for influenza
patients.
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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?
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Hospital B
In an effort to save its very ill patients, Hospital B has
decided to reserve its remaining cache of oseltamivirfortreatment of the sickest influenza patients. Thisapproach isconsistent with the usual practices ofproviders at Hospital B, who are accustomed tofocusing primarily on treatment. Hospital B is relying on
airborne infection isolation and personal protectiveequipment, namely N-95 respirators, gloves, andgowns to protect its staff, and is not using oseltamivirfor prophylaxis.
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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 beprepared to sacrifice to treat the worst off?
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Hospital C
In order to maximize survival rates, Hospital C has
decided to reserve its remaining cache of oseltamivirfortreatment of the patients most likely to benefit,namely those who present within 48 hours of diseaseonset. As this prioritization plan will result in fasterdepletion of the antivirals, Hospital C is relying on
airborne infection isolation and personal protectiveequipment, namely N-95 respirators, gloves, andgowns to protect its staff, and is not using oseltamivirfor prophylaxis.
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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?
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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.
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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
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Hospital E
Hospital E has decided to give preference to
younger patients who have been exposed andnot to treat patients over 70
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Justification
Patients who die at a younger age will have
had less of the good of life years than olderpatients.
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
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What does this case show?
In thinking through how to distribute antivirals
in a pandemic, one quickly finds oneselfaddressing 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?
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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
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