Biomedical Ethics

1
Thurs. 2/10

Lectures tues thurs, conference at mon- 1 group meets at 8:30 upstairs, or 9:30 which will
begin running next week so keep checking
- the conference starts 20th of sept, next Monday labour day theres no class or lecture, sept
13 theres no lecture or conference
PHIL343
Monday, tues, thurs

- we don’t assume any knowledge about philosophy of this course

- we have 2 short assignments before the mid-term essay, then mid-term essay (TA will
have a session to discuss it)
- we focus on 1 particular aspect of biomedical ethics, micromedical/bio ethics (abortion,
euthanasia, etc.)- about the rightness or wrongness of individual action performed by a
physician etc.
- in this course we do not discuss micromedical ethics, we focus on Population-level
medical ethics, that’s about the health care system not individual aspects like the doctor
- so we discuss the normative health care system, and ethical foundations for analyzing
and evaluating the health care systems in different nations
- difficult book to read, it assumes some knowledge about theories of justice (so we’ll
learn a bit about those next week)
- the 2nd half will be group research for 3-4 sessions, and then 3 sessions of actual
presentations!

- legal judgements and ethical judgements are different

- read article by Tuesday

Sept 7/10
- conference starts on sept 20

Euthanasia Two Distinctions, 4 Categories

Active
Voluntary Active Voluntary
Mercy killing at the
person’s request (e.g.
phyician-assisted suicide)
- legal in sweeden, Belgium
etc. but there are lots of
conditions (patient must be
fatally ill, include severe
pain
Non-voluntary Active non-voluntary
Mercy killing without the
person’s consent
Passive
Passive Voluntary
Letting the person die at her
request(Acceptable)
- in Quebec we can go this
far
Passive non-voluntary
Letting the person die
without her consent
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Quebec

2003: the Supreme court of Canada ruled that the charter does not include the right to
botain physician assisted suicide (sue Rodriquez v. BC 1993)
1992: The Quebec superior court ruled that a competent, adult patient suffering from an
incurable disease and bedridden for life had the right to request that her doctor disconnect
the respirator keeping her alive (Nancy B. case)
- Mr. Justice Dufour “no one can be made to undergo treatment without consent”

The Preston Curve

- proposed by Preston, this regards the relation between wealth and health
- strong correlation between health and wealth up until 70yrs old, and then it diminishes
quickly, and then there’s a weak correlation about 700
‘
- lots of things affect our health condition but its not just health care that contribute to our
health condition

Sept 9/10

Relevant consideration to biomedically relevant ethical decisions:

1. Urgency
2. Financial situation/economic situation
3. Family (dependants)
4. Future wellbeing/ benefit
5. Type of occupation (determines the benefits you get)
6. Credentials/qualifications
7. Service to society/moral character

- some of these should/shouldn’t affect our moral judgement

- our judgement is very complex, you must justify which one is relevant and which one is
not

Sept 14/10

Utilitarianism and Rawls

Utilitarianism
Classical Utilitarianism: an act is right (health care system is just) if and only if it
produces the greatest total sum of peoples well-being (health)- net benefit
- very popular doctrine in political philosophy and in health care distribution
Average utilitarianism: an act is right (health care system is just) if and only if it
produces the highest average of people’s well-being (health)

* right- wrong (1-place redicate) X is wrong/right

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*good-bad (2 place predicate) X is better than O
- teologist can infer things from saying something about X, about O
- anti-deontology or deontology, the rightness or wrongness of an act is independent of
good or bad

Utilitarian Philosophers
- Jeremy Bentham (1748-1832)
- John Stuart Mill (1806-1873)
- Henry Sidgwick (1838-1900)
- Richard Hare (1919-2002)
- Peter Singer (1946---)

Jeremy Bentham (1748-1832)

- improvement of prison conditions
- defense of homosexuality
- the founder of University College London (1826): non-conformists, Jewish people, and
catholics
- parliamentary reform
- animal welfare

John Stuart Mill (1806-1873)

- economist: principle of political economy (1848)
- human rights and an anti-slavery activist (1850)
- philosopher: utilitarianism (1863)
- women’s rights and freedom : the subjection of women (1869)
 womens suffrage
 state supported education for all

Basic Features of Utilitarianism

*Consequentialism: an act is right if and only if it maimizes the goodness of outcomes
*Sum-Ranking: the goodness of outcome is given by (W1+W2+W3+….+wn) in the n-
person society
* Welfarism: what matters is people’s utilities
*Mental states: peoples utilities are defined in terms of their mental states

Rawl’s Criticisms
- the separateness of persons
- instability- inequality (kill 1 healthy man to save 4 people who need organs)
- mental states (ex/ adaptive preference formation- if you go to India, women are not
treated very nicely, so those poor women who don’t have access to health care,
education, etc., and they don’t seem to be having a good life but if we feel mercy for
them then their pleasure shoots up very quickly)
 we cannot ignore the importance of mental states but we cant ignore other things

Assumptions for Social Contract

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- society as cooperative venture
- parties: free and equal
- enough resources to meet everyone’s basic needs- but moderately scarce

Rawls Original Position

- parties: rational and self-interested
- behind the veil of ignorance parties don’t know:
 the race, ethnicity, gender, age, income, wealth, natural endowments,
comprehensive doctrine, etc. of any of the citizens in society, or to which
generation in the history of the society these citizens belong
 the political system of the society, its class structure, economic system, or level of
economic development
- parties do know;
* that citizens in this society have diff comprehensive doctrines and plans of life
* that the society is under conditions of moderate scarcity
* general facts about human social life; facts of common sense; general conclusions of
science (including economics and psychology) that are uncontroversial

Two Principles of Justice

First principle: each person has the same indefeasible claim to a fully adequate scheme
of equal basic liberties, which scheme is compatible with the same scheme of liberties for
all;
Second principle: Social and economic inequalities are to satisfy two conditions:
1. they are to be attached to offices and positions open to all under conditions of fair
equality of opportunity;
2. they are to be to the greatest benefit of the least-advantaged members of society
(the difference principle)
- lexically prioritized, first principle always dominates 2nd principle

The Difference Principle

- social and economic inequalities can be justified only when they maximize the state of
the worst off group in society (Maximin rule)
- compare X= (20,10), and Y= (15,12)
- Compare X= (20,10), and Z (25,12)
- primary social goods; liberty, opportunity, income, wealth, and the social basis of self-
respect (goods or items which any rational people could want to have more of)
- you can justify any level of economic inequality as long as your benefiting the worst of
group in society…we don’t care about the size or degree of inequality, or the total
amount of well being in society
- this principle appears odd

Sept 16/10

Assignment announced Monday at 10:30, due Friday at 11:59pm

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- John Rawls is social contract theory, rational parties will chose the 2 principles of
justice, which consist of 3 parts; priority of liberty (assigned gurantee to individuals
equally), fair equality of opportunity (difference principle)

Rawls’ reflective Equilibrium

- a balanced coherent, and stable state among a set of briefs after the parties adjust the
general principles and particular judgment
- first we identify the plausible rules of health care resource allocation, if you start
implementing this rule then you will encounter a lot of exceptions, counter-intuitive
cases, the cases you didn’t anticipate so the idea of reflective equilibrium allows us to
adjust our general principle that we’ve already chosen….so theres general rules and our
intuitive judgement, so we try to adjust general principles in the actual world
- so the process- seemingly plausible abstract rule, we apply that and modify it a tiny bit
but we don’t change the basic structure of that principle

Rawls: Key concepts

Social contract theory: society as cooperative venture (social contract amongst free and
equal parties- everybody must get benefit from being in society and social cooperation)
- original position and the veil of ignorance, nobody knows what position they begin in,
they could have a deformity or a disadvantage and they don’t know it

Nozick’s criticism and his Libertarianism

- Nozick does not disagree with Rawl’s first principle, but…
- strongly disagrees with…
*the difference principle
*foundations for social contract
- individual rights constraint social and collective action, if you allow any resdistributive
principle or oversized gov’t then you’re using other people for your own benefit, and this
is really bad thing to do (using other people as a mere means)
Ex/ suppose a famous NHL player comes to the habs, they raise the price of ticket
because of that player, and still lots of fans are looking to buy that ticket and come to the
bell center, the extra money for that player must GO to that player, if the fed gov’t
impose tax on that, that’ll be forced labour for the gov’t
- you just stick to your own right, private property rights, objects outside of your body
- theres so idea of justice in libertarianism, justice only concerns how you obtained that
property, “acquisition” and “transfer” of private properties
- doesn’t say much in health care resource allocation
- but this idea is strongly opposed to the difference principle, they don’t have a strong
objection to Rawls first theory of justice (on liberty and freedom), but hes strongly
opposed to the difference principle because he thinks its exploiting other people as a mere
means
- individual rights constrain social and collective action
- justice is concerned with “aquistion” and “transfer” of private property
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Sen’s criticism and his capability approach

- on the face of it, he agrees with Robert Nozicks libertarianism, individual freedom
which should be our focus in just society, but his understanding of freedom and justice is
quite different
- thinks we should guarantee and assign liberty to everyone
- he tries to put all of Rawls principles into 1 thing
- he’s an egalitarianism, he wants to endorse liberty and redistribution among individuals
- first he starts criticizing primary social goods, saying they ignore the diversity amongst
individuals (theres a bundle of goods you have, and what you divide from them is
different, each person derives diff things from primary social goods, e.g. suppose there is
a bike, I am not disabled so I can move around mtl just fine, I can therefore derive
mobility from the bicycle, suppose I give it to a man with severe disability, that guy
cannot use the bike therefore he cannot derive the function of mobility from the bike)
- he derives that as capability to function as a focus of justice which gives you a complex
idea of justice…everyone has diff physical, genetic, environmental conditions, there’s no
point to endorse equal income, but equality of capability to function for everyone
- derives notion of capability to function from the criticisms of Rawls social goods
- the difference from Rawls and Nozick is that Sen endorses equality of capability to
function….Rawls says social and economic inequality is ok when it benefits and
maximizes the level of the good in the worst off we can justify any level of social and
economic inequality
- so Rawls was concerned with inequality, while Sen was concerned with “equality” and
“capability of function” (Rather than maximizing the level of the primary social goods
that are representative person in the worst off group possess)

COMPREHENSION QUESTIONS
- Explain Rawls’s criticism against utilitarianism?
- Explain the assumptions imposed on the parties in the original position
- Explain rawls’s two principles of justice
- How does the difference principle identify the worst off group in society?
- Explain the notion of reflective equilibrium. Identify a real world example, where
we use this method.

Questions for further thought…

- are Rawls’s criticisms of utilitarianism plausible? Can we defend utilitarianism
from Rawls’s criticisms?
- Is the rational choice behind the veil of ignorance a plausible method for
identifying the basic structure and rules of society?
- Is the difference principle more acceptable than average utilitarianism?

- one criticism of the mental sates account, like utilitarianism, is called the “experience
machine”. Suppose there’s an experience machine with big water pool and you are
plugged into that experience machine and you are floating in the swimming pool, and so
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long as you’re plugged into it you have unlimited pleasure for an unlimited period, but
physically speaking you are just floating….would you plug into that experience machine?
– economics for example on cares about mental states, they don’t care about any other
things, so the experience machine may sound trivial and stupid, but millions of econ
students and profs would say I would hook up or their theories depend on that premise
 this can be a reason to favour the difference principle

Sept 21/10

The Place of Health (and/or health care) in Rawls’ theory of justice

- he doesn’t mention health and health care, but it seems to be a major part of
justice and basic social/economic structure – on the face of it, we think we should
include health care in the difference principle, where we maximize the worst off
in terms of primary social goods- the goods rationale people would want if they
didn’t know which place they would have in society
- we have bad and good luck, and these are not our choices given by circumstances
or social institutions or from parents that you didn’t choose
- so if we happen to be in the original position, they would choose the difference
principle b/c they don’t know where they are in society (some happen to be really
well off, others happen to be very very poor)
- so health and health care are rational goods than anyone would want to have
(good)
- if there are inequalities in terms of health, we should compensate, or try to
minimize them to bring up the level of health in society (inequality)
- if you have 2 patients in hospital, 1) cut finger, 2) severe pain, you had to choose
1, you would chose the 2nd one because its more serious and it’s a worse health
condition, so you are giving priority to the worst off
- so its not so ridiculous to imagine that Rawls would have said that health should
be considered in the difference principle, so health and health care would be
dominanted by fair equality of opportunity
- if we have 1 patient with no health care, and another with health care, its not
entirely clear what he would do, but on first reading, the first principle must
respect the individuals rights, in which case the first principle dominates any part
of the second, so one interpretation would be that we should take priority to the
guy who has health insurance but with minor injury

Where is health (and/or health care) ?

- as one of primary social goods (Kenneth arrow)
- how do we apply the difference principle?
- There are a bunch of different interpretations because primary social goods include
liberty, wealth, income etc. so adding health to this means
1. mazimize the level of the worst off group in terms of primary social goods, allows a
trade off between goods, health increases even though it declines but income increases
more
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2. maximize the level of the worst off group in terms of health, so we divide and
maximize the level of the worst off in each item, so we maximize the level of the worst
off group in terms of income, assets, then health etc. so we maximize in terms of each
item, so this doesn’t allow tradeoff between 2 goods (ex/ income/health)

Arrow’s Example
- consider the haemophiliac who needs about $400 worth per annum of coagulant therapy
to arrive at a state of security from bleeding at all comparable to that of the normal person
(p.254)
- so if you take the first application of the diff principle, then we should do some trade off
between income and health, so we should give more money to this patient b/c his health
condition is bad and in order to attain the normal functional level then he needs to be
compensated for it
- according to the 2nd interpretation, they think there should be no trade-off, we should
give him unlimited health care, so theres no connection between healthcare and income
- if you take first interpretation, the problems may include
1) index-number problem
- tradeoff between money income and wealth seems to be ok, but in other cases this trade
off is totally implausible, and ethically wrong so we must be weary and look at all cases
- this problem arises whenever you measure something
- contentional measure is GDP, how much income/wealth, and then they decided they
should include health and education (so health, education, income) but its hard to define
these b/c its hard to define a common matrix which bridges these 3 different indicators
- in Arrows criticism he points out 2 problems in the first interpretation;
- comparing the cardinal numbers of different groups and trying to measure it, its kind of
incomparable

2) interpersonal comparability; this isn’t as serious, but its still an issue of how we
compare them
- its very hard to measure someones health in comparison with somebody else
- ex/ Patient A comes to the hospital, he’s been having severe pain for a day, patient B
has mild pain, but he’s had in for a year…who’s worse off? Its unclear
- some say we should just consider who’s been suffering the most and ignore the time,
other people say the opposite

Other Criticisms’ against Rawlsian theory of justice

1) maximize the level of the worst off? Is that really good? suppose we measure health,
utilitarianism says we should chose x rather than y because total health is maximized
- difference principle says we should chose y because the difference is smaller, but x is
great equivalent
x = (10, 5)
y= (8, 6)

- difference principle would chose y over x, even if y’s total health was greater than x
(which is favored by utilitarianism), but if you chose overall health the difference
principle maximizes level of worst off but that allows still a large inequality in terms of
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health, b/c if 8 goes up to 12, Y is still the best option b/c 6 is still higher than 5, when is
the level of the worst off

2) Trading health risk for higher income? This is absolutely fine, some people are willing
to take health risk for a higher income which is fine, this sounds plausible but it also
sounds very horrible, b/c poor people engaging in prostitution take a lot of risks

3) health must be independent of income, wealth, liberty, social basis of self-respect

- health is distinctive and special, if you don’t have health you cannot work, you cannot
study, so it must be the most important thing
- Norman Daniels says that health is special, so he takes the 2nd interpretation of justice
and then he doesn’t think that health and health care should be in the difference principle,
it should be considered at the level of fair equality and opportunity

Equality of Health
The Levelling down objection; lowered the level of the best off person to the level of
the worst off benefits noone, taking money from the rich and burning it to level them
down then noone wins
- if you think equality is good, then leveling down is equal, but theres nothing good about
forcing leveling down
Health equality between smokers and non-smokers? If we treat equality these 2, is
that plausible? No
We should Not pursue equality of health, but equal access to health care.

Sept 23/10

- Norman Daniels holds the most comprehensive theory of justice in English speaking
biomedical ethics
- we have to have principles to justify priority setting, that’s why we need population
level biomedical ethics
- another issue is the concern for growing inequality in most parts of world
- Norman daniels appeals to Rawlsian theory of justice

3 focal questions
1. is health, and therefore healthcare and other factors that affect health, of special moral
importance?
2. when are health inequalities unjust?
3. how can we meet health needs fairly under resource constraints? Health care resources
are limited. You must have principles that can be justified to every patient

Daniel’s Project
- his theory of justice considers not as a part of primary social goods like the diff
principle, he thinks it should be understood as fair equality of opportunity
- so he thinks that health is different from the social basis of self-respect (income, wealth,
liberty, etc.)
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- health: is part of fair equality of opportunity, the 2nd principle in Rawls theory of justice,
rather than the difference principle
- its wrong to start with the notion of right to health or right to health care, we can talk
about right only if it can be harvested from an acceptable general theory of distributive
justice or from a more particular theory of justice for health and health care (p.15)
- people do not have rights before we talk about the theory of justice
- the implications of this is very significant as we will see later, as the human rights say
we have a basic right to health care…this view rejects that
- so this is debatable
- but once you start talking rights, it silences other people, and if we can meet anyones
rights then that’s fine but that requires unlimited resources
- under scarce resources, we cannot satisfy some peoples basic rights to health and we
know that so we should set aside the issue of human rights to health care
- we should have some kind of a process that can relieve the disagreement and anxiety
feeling between diff patients, so we need to understand what other people would say
about this situation

1. Is health of special moral importance?

- people who tolerate vast inequalities in wealth and power are often morally outraged
when those who are ill cannot get care because they cannot pay for it (p.18)
- so he doesn’t start with equality of income, he begins with equality of health…so that
starting with this intuition, we can lead to income

2. When are health inequalities unjust?

- health inequalities across social groups- by race or ethnic group, class or gender- occur
in all society (22)
- but then we have smokers/non-smokers? Genetic? Gender?, so is this unjust? When its
beyond our control?
- some people have a genetic makeup that makes them more likely to develop a certain
disease, is this ok?
- men and women should have same life expectancy but why do we women live longer
than men?
- historians say if you look back to all prevalent societies, life expectancies between men
and women is more or less the same…also you don’t see women working on construction
sites doing hard labour

3. how can we meet health needs fairly under resource limits?

- to propose a fair deliberative process to reduce disagreements about resource allocation
- in cancer research, if the result is that we can extend the life of a person by 6 months,
with a success rate of 60% higher, then that’s a big deal in cancer research

Assumptions in the rest of course

- were going to consider these 3 focal questions to have a rough idea of the just
health and health care system, also we’ll look at particular difficult cases in each
question
1) disability discrimination in health care
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2) aids discriination
3) priority setting; pandemic influence and distribution

- our assumptions; the government has a responsibility to health and welfare; we can
apply our discussion to organized health care but we assume we have publicly funded
health care system, and publicly delibered health care

Comprehension questions;
1) what is Arrows criticism of Rawls notion of primary social goods?
2) Allegedly, the difference principle does not care about the total of peoples well-
being or inequality of peoples well-being. Make examples to illustrate these
allegations
3) Explain the leveling down objection to equality of health