THEORIES AND PRINCIPLES

OF HEALTH ETHICS B. Micro- and Macro Allocation of Health

Care

JUSTICE
What is Justice?
The maintenance or administration of what is just
especially by the impartial adjustment of
conflicting claims or the assignment of merited
rewards or punishments. (“Merriam-Webster
Dictionary,” 2021)

“The constant and perpetual will to render each

his due” - Institutes of Justinian

A. Formal and Material Justice

The principle of justice is often equated to
an obligation to be fair in the distribution of
benefits and risks.
1. Formal Justice
In distribution, equals must be treated
equally, and unequals must be treated
unequally.
- Does not attempt to provide any criteria for
the determination of equality
- Does not state in what respect equals are
to be treated
- Any criteria could be used such as:
- Age
- Sex
- Marital Status
- Land Ownership
2. Material Justice
"Physicians should merit the confidence of the
Principles that specify relevant
patients entrusted to their care, rendering to each
characteristics or morally relevant criteria in
a full measure of service and devotion."
regard to treatment are said to be material
(Principles of Ethics of the American Medical
principles and form the basis of material justice.
Association)
Common Methods of Distribution of Goods However, situations like resource scarcity make it
and Resources difficult to give full measure of service and
● To each person an equal share devotion. Now, how should one determine the
● To each person according to need appropriate method of allocation?
● To each person according to merit
● To each person according to contribution MICRO AND MACRO-ALLOCATION OF
● To each person according to effort HEALTH CARE
● To each person according to social worth
● When the need or demand for healthcare
Fair Opportunity Rule resources exceeds the available supply,
No persons should be denied social benefits on resources must be distributed on some
the basis of undeserved disadvantages. basis. This leads to rationing.
 ● Rationing often refers to general
limitations placed on the availability of
certain types of healthcare
● Distribution of healthcare at a broad
institutional or societal level is referred to
as macroallocation.
● Macroallocation includes the way a
hospital budgets its spending, as well as
the amount of resources a nation devotes
to primary and preventive care compared
with high-technology curative medicine
and nonmedical activities such as
education and defense.
● Microallocation, on the other hand,
focuses on treatment decisions regarding
particular persons. It may entail deciding
which of beneficial treatments to provide
an individual patient, particularly when
only a limited time is available for
treatment.
MACRO-ALLOCATION; TWO-TIER SYSTEM
● Two-Tier System, everyone would be
guaranteed coverage for basic care and
needs
● The second tier system, based on the
ability to pay, would provide expanded
and perhaps better care at private
expense
Oregon rationings system
● An approaching concept of a two-tier
system which was put into placed to
extend the benefits of health care to a
wider population.
● In 1983, in response to a desire to
expand the number of Oregonians who
received an acceptable level of medical
care, the state began to hold public
meetings in regard to health policy. These
meetings culminated in the formation of a
group known:
o Citizens Health Care Parliament:
(produced two reports)
- Society Must Decide
-Quality of Life in Allocating
Health Care Resources
The Oregon Health Services Commission
● Used cost-benefit analysis, set out to
assess the relative value attached to each
medical service by the citizen of the state.
Each service was ranked on three factors:
1.The public’s perception of
value
2.The effectiveness or outcome
3. Cost
● The services considered most valuable on
the basis of public perception,
effectiveness and cost were prenatal care
and those least valued were those
involving infertility and cosmetic surgery
● The goal was to expand the number of
citizens eligible for care
● However, later on, Oregon abandoned its
emphasis on cost-effectiveness analysis
and increasingly ranked procedures on the
basis of clinical effectiveness and social
value.
● Oregon modified the plan over time
resulting in decreased coverage, reduced
access to services, and increased costs.
MICRO-ALLOCATION
Can be associated with the analogy of lifeboat
ethics, Who shall be saved from drowning and
what will be the criteria for selection?
Case Situation:
On a busy night in the ER a member of the
hospital board comes in with her sick child and
asks that you see him right away. The child has a
sore throat and red eye and he appears subdued,
but alert. You have a full waiting room.
What should you do?
WHAT RULES GUIDE RATIONING
DECISIONS?
● Rationing means the distribution of any
needed thing or procedure that is in short
supply to those who need it in accord with
a set of rules that assure fair distribution.
 ● The reasons for shortage can be many.
For example,
o there are many more patients
with end stage cardiac disease or
liver disease than there are
cadaver organs available;
o expensive equipment may be
lacking in a particular region;
o tertiary care hospital beds may
be limited; a particular medication
may be extremely costly;
o few personnel might be trained
for a certain technical procedure,
oInsurance coverage is unavailable
or of prohibitive cost.
o Every physician rations his or
her own time available to provide
medical services.
● Criterion for rationing decisions
o Social Worth- discrimination
oLikelihood of medical benefit -
many more patients required
dialysis than there were machines
available.
oSeriousness of need – can be
manipulated
o First come, First-served Basis
ARE THERE ETHICAL CRITERIA FOR
MAKING TRIAGE DECISIONS?
● Triage (which means "choice" or
"selection") is required when many
patients simultaneously need medical
attention and medical personnel cannot
attend to all at the same time, such as in a
disaster or in the crowded emergency
department of an urban hospital.
● Common Sense Rule - serve persons
whose condition requires immediate
attention
● ·The rules of military triage, developed
centuries ago, direct the physician to
attend first to those who can be quickly
and successfully treated in view of a
speedy return to the battlefield, or to treat
commanders before troops in order to
assure leadership.
● Disaster triage is applied to civilian
disasters by treating persons, such as
firefighters or public safety officers, who
can quickly return to duty and help others.
CAN I MAKE ALLOCATION DECISIONS
BASED ON JUDGMENTS ABOUT
"QUALITY OF LIFE"?
Under conditions of scarcity, the question may
arise whether a patient's quality of life seems so
poor that use of extensive medical intervention
appears unwarranted. When this question is
raised, it is important to ask a few questions.
● First, who is making this quality of life
judgment, the care team, the patient, or
the patient's family? Several studies
have shown that physicians often rate the
patient's quality of life much lower than the
patient himself does.
● If the patient is able to communicate, you
should engage her in a discussion about
her own assessment of her condition.
● What criteria are being used to make
the judgment that the quality of life is
unacceptable? These criteria are often
unspoken and can be influenced by bias
or prejudice
● How could this patient population be
supported in ways that might improve
health?
Quality of life judgments based on prejudices
against age, ethnicity, mental status,
socioeconomic status, or sexual orientation
generally are not relevant to considerations of
diagnosis and treatment. Furthermore, they
should not be used, as the basis for rationing
medical services

C. Theories of Justice
In determining the appropriate method of
allocation, we have 3 theoretical positions as our
basis - egalitarianism, utilitarianism, or
libertarianism.
1. Egalitarian theories
- Emphasize equal access to goods and
services
- Believe that we must find a way to provide
universal health care to all
- Most extreme form - any deviation from
equality is unjust
- They fail to take into account the scarcity
of human resources relative to human
wants
- Blame human error like waste, fraud, or
the political system for the issue of
inequality and do not recognize scarcity as
the problem (veil of ignorance)
a. Contract Theory of John Rawls - a social
arrangement is an agreed-on contract to
advance the good of all who are in the
society.
- All would work toward the equal
distribution of goods and services, unless
an unequal distribution would work to
everyone’s advantage
- Beauchamp and Childress have argued
that this collective social protection and
the fair opportunity rule form the basis of a
right to health care
b. Life span allocation by Norman Daniels
- “Prudent life span”
- Rejects the idea of viewing age groups as
competitors but rather frames the situation
as a single prudent individual.
- Here, the individual reasons toward a
prudent allotment of healthcare resources
across different life stages
- More on what would i choose for my own
life instead of “us against them”
- Makes the assumption that the prudent
decision of the individual on how to
allocate resources over their lifespan
would be considered prudent by
fair-minded participants of a fair
deliberative process
*prudent - acting with or showing care and
thought for the future
- Uses the concept of “veiled prudence” - 4
key elements:
● The prudent planner does not
know her age
● The prudent planner is ignorant of
her conception of the good,
although she knows she might
want to alter her conception of the
good in the course of her life,
therefore she keeps her options
open for revisions in the future
● The prudent planner is guided by a
time neutral concern for her
well-being over the lifespan
● The prudent planner has to plan for
each stage of her life under the
assumption that she will live
through it
c. Fair Innings Argument - hold that there is a
finite span of years that we consider a
reasonable lifetime (ex. life expectancy at
the time of birth)
- Not reaching this goal is considered an
injustice because they did not receive their
reasonable share of life
- Those who exceed their life expectancy
have received a bonus
- Argument that everyone should be
provided an equal chance to have a full
set of fair innings, to reach their
appropriate life expectancy
- Once they receive it, they received their
full entitlement
- Each person’s desire to stay alive should
be regarded with the same importance
and as deserving of respect as anyone
else, regardless of the quality and duration
- True in all cases where we have to choose
between lives, except one, in situations
where one has received full innings and
one has not
- Unfair if the person who has not loses to
the person who has (ex. Older vs.
younger) - younger should win
2. Utilitarian theories
- Emphasize a mixture of criteria so that
public utility is maximized
- Public utility - “the greatest good for the
greatest number of people”
- Accept political planning and intervention
as methods of redistributing goods and
wealth to bring about public utility
a. QALYs (Quality adjusted life years) by
Daniel Callahan - used to measure the
cost-benefit of applying a particular
medical procedure
- Health care should be provided only to
those who will benefit most (those with
good quality of life) and denied from those
who will benefit the least (those with a bad
quality of life).
- One Qaly = 1 year of perfect health
- If health is below the maximum, Qaly < 1
per year
- Dead = 0 QALY
- Negative QALY = “worse than dead”
- QALY measures are used to reflect the
quality and quantity of life added owing to
incurring a particular medical expense
- Although it is clear that it is wasteful and
we cannot “afford everything for everyone”
in health care, and some form of rationing
must be made, do you think Qaly is the
right answer?
● Ex. Stephen Hawking - motor
neuron disease but one of the
greatest scientists; Beethoven -
deaf but a great pianist that shaped
classical music
b. Natural life span argument by Daniel
Callahan
- Natural life span ends in a natural death
and that this occurs at the end of the life
cycle
● One’s life work is completed
● One’s moral obligations to people
one is responsible to have been
discharged
● One’s death does not seem to
others an offense to sense or
sensibility or tempt others to
despair and rage at human
existence
● The process of dying is not marked
by unbearable and degrading pain
- Allocating resources for oneself over one’s
whole life
- Principles for practice
● After a person has lived out a
normal life span, medical care
should no longer be oriented to
resisting death
● Medical care following a natural life
span would be limited to relief of
suffering
● The existence of technologies
capable of extending life beyond a
normal life span creates no
technological imperative for its use
- With a closed system, money saved from
not providing life-extending technologies
could be used to invest in childhood health
and provide better maintenance for the
elderly
3. Libertarian theories
- Emphasize personal rights to social and
economic liberty
- Not concerned with nor do they outline the
requirements of, how the material goods
and services are to be distributed, only
that the choice of the allocation system be
freely chosen
- The free-market system has been
criticized, as it has not created a unified
system of health care delivery within our
nation but a whole series of micro systems
- May coexist within any national health
care plan we evolve
D. World Healthcare Models (starts at
american healthcare today)
WORLD HEALTH CARE MODELS
4 general models
1. The Beverage Model
2. Bismarck Model
3. National Health Insurance Model
4. Out of Pocket Model
THE BEVERAGE MODEL / BEVERIDGE
MODEL
- Originated in Great Britain
- Practised in
- Great Britain
- Italy
- Spain
- Hong Kong
- most of Scandinavia
- New Zealand
- Cuba
- US department of Veterans affairs
- Health Care is financed by the government
and is taxed based rather than insurance
based
- Purest form of this model is practiced at
- Cuba and US department of
Veterans affairs
- Many, but not all, hospitals and clinics are
owned by the government; some doctors
are government employees, but there are
also private doctors who collect their fees
from the government.
- People can choose to be treated in
the private or public sector
- Large number of primary care physicians
- Increased use of preventive
services
- Less hospitalization
- Less use of the emergency
department
- Less cost in the long run
- Cost are controlled by rationing
 - Covers everyone but does not cover
everything
- Doctors receive free education and never
sued for malpractice
- Long wait times for non-acute secondary
and tertiary cases
- New technology is not always available
- The government can influence what the
doctors can do and what they can charge
- get it, and those that do not stay sick or
THE BISMARCK MODEL
- Named after Chancellor Otto von
Bismarck (statesman who unified and
modernized Germany in the late 19th
century)
- The health care model found in Germany,
France, Japan, Belgium, and Switzerland
- Health care providers and payers are
PRIVATE ENTITIES
- Uses insurance companies
- The plan uses private non-for-profit health
insurance plans called “sickness funds”
usually financed by employees and
employers through payroll deductions
- Unlike American health care insurance
plans, these non-profit entities are
basically charities and cover everybody.
THE NATIONAL HEALTH INSURANCE MODEL
- Used in Canada, Australia, Taiwan, and
south Korea.
- Health care providers are private, but the
payer is a government-run insurance
program that all citizens pay into.
- All insured residents are entitled to same
level of health care which includes
hospitals, physicians, and surgical
dentists.
- Insurance plan collects monthly payments
and pays medical bills.
- Because this is not a free-market system,
there is no profit motive, no need to
advertise, and no expensive underwriting
offices.
- As a single payer system, the national
system has great leverage and market
power to negotiate lower prices.
- Cost containment is also gained by limiting
the medical services that can receive
reimbursements, and by making patients
wait to be treated.
THE OUT OF POCKET MODEL
- Practiced in 40 countries
- Rural Africa, India, China, South
america.
- the out-of-pocket model, is what is found
in the majority of the world. It is used in
countries that are too poor or disorganized
to provide any kind of national health care
system. In these countries, those that
have money and can pay for health care
die
- hundreds of millions of people go their
whole lives without ever seeing a doctor.
PATIENT PROTECTION AND AFFORDABLE
CARE ACT
E. Affordable care act
1. Initiated a multiyear overhaul of
health-insurance industry that
covers all american citizens
F. What the affordable health care act does
1. Taxes 35% of premiums for small
business that provide health
insurance
2. Rebates to seniors for out of
pocket drug cost due to gap in
medicare prescription
3. Prohibits insurers from dropping
customers when they get sick
4. Prohibits denial of coverage of
anyone with pre-existing condition
5. Prohibits lifetime caps on
insurance plans until age 26
6. Insurers required to spend at least
80% of premiums on medical
services
7. Provides subsidies to individuals
and families with incomes up to
400% above poverty lines to help
them buy health insurance
8. Requires most americans to
purchase health insurance.
9. Medicade eligibility expanded to
anyone earning up to 133% of the
poverty level
10. Establishes health insurance
exchanges to serve as a
competitive insurance market
enabling those without
employer-based insurance to shop
for coverage
11. Creates independent payment
advisory board or IPAB
 12. Phases in a series of fees and
taxes on the health industry
G. Standards of Care
STANDARDS OF CARE
- What the law requires that health care
providers conform to specific standard of
care
- For nurses, they assume a duty to provide
care to their patients with the degree of
skill and knowledge ordinarily possessed
and exercised by other nurses
- For health care providers, they are
expected to act with professional judgment
wherein this judgement must remain within
the bounds of accepted practice for that
specialty group
- The courts, over the last several decades
have moved toward a national standard of
care rather than allow for a local focus
➔ CONTINUING EDUCATION AND
NATIONAL CONFERENCES
❖ Important elements of current
health care practice as the national
standards for specialties continue
to rise
- As humans, we responsible for both our
actions and failure to act
- Under common law, we are held to the
“reasonable man” standard
➔ REASONABLE MAN STANDARD
❖ This standard has evolved as a
fairness standard
❖ We may be charged with
negligence if someone is injured
because we failed to perform an
act that a reasonable person would
do in a similar situation, or if we
commit an act that a reasonable
person would not commit
- For health care providers, they are held to
higher standard than laypersons, for
example:
● If a patient is injured because a
specialist failed to exercise the skill
and expertise that under similar
circumstances could reasonably be
expected of a professional with
similar experience and training,
then that specialist may then be
liable for negligence.
- Differing levels of education, training, and
specialization then gives rise to differing
standards of care required.
Other relevant ethical principles
1. Principle of Double Effect
2. Principle of Legitimate Cooperation
3. Principle of Common Good and Subsidiary
Principle of Double Effect
- This doctrine says that if doing something
morally good has a morally bad side-effect
it's ethically OK to do it providing the bad
side-effect wasn't intended. This is true
even if you foresaw that the bad effect
would probably happen.
- The principle is used to justify the case
where a doctor gives drugs to a patient to
relieve distressing symptoms even though
he knows doing this may shorten the
patient's life.
- This is because the doctor is not aiming
directly at killing the patient - the bad result
of the patient's death is a side-effect of the
good result of reducing the patient's pain.
Factors involved in the doctrine of double
effect
● The good result must be achieved
independently of the bad one: For the
doctrine to apply, the bad result must
not be the means of achieving the good
one. So if the only way the drug relieves
the patient's pain is by killing him, the
doctrine of double effect doesn't apply.
● The action must be proportional to
the cause: If I give a patient a dose of
drugs so large that it is certain to kill
them, and that is also far greater than
the dose needed to control their pain, I
can't use the Doctrine of Double Effect
to say that what I did was right.
● The action must be appropriate (a): I
also have to give the patient the right
medicine. If I give the patient a fatal
 dose of pain-killing drugs, it's no use
saying that my intention was to relieve
their symptoms of vomiting if the drug
doesn't have any effect on vomiting.
● The action must be appropriate (b): I
also have to give the patient the right
medicine for their symptoms. If I give
the patient a fatal dose of pain-killing
drugs, it's no use saying that my
intention was to relieve their symptoms
of pain if the patient wasn't suffering
from pain but from breathlessness.
● The patient must be in a terminal
condition: If I give the patient a fatal
dose of pain-killing drugs and they
would have recovered from their
disease or injury if I hadn't given them
the drugs, it's no use saying that my
intention was to relieve their pain. And
that applies even if there was no other
way of controlling their pain.
Problems with the doctrine of double effect
Some philosophers think this argument is too
clever for its own good.
● We are responsible for all the
anticipated consequences of our
actions
● Intention is irrelevant
● Death is not always bad - so double
effect is irrelevant
● Double effect can produce an
unexpected moral result
PRINCIPLE OF LEGITIMATE COOPERATION
● To achieve a well-formed conscience, one
should always judge it unethical to
cooperate formally with an immoral act
(that is, directly to intend the evil act itself),
but one may sometimes judge it to be an
ethical duty to cooperate materially with an
immoral act (that is, only indirectly intend
its harmful consequences) when only in
this way can a greater harm be prevented,
provided:
➢ that the cooperation is not
immediate and
➢ that the degree of cooperation and
the danger of scandal are taken
into account
DEFINITION OF TERMS:
● Moral Object - the moral object of an
action is the objective goal of the action. It
is the good that you are trying to attain (or
the evil you are trying to avoid) through the
action, and how well the action is ordered
toward that good.​
● Intention - is the reason why you choose
to act​. Your intention may coincide with
your choice of the moral object, or you
may have intentions beyond the simple
object. For example, you may choose to
give money to charity (the moral object to
help those in need), but your intention may
be to impress people with your generosity.
● Legitimate - refers to moral acceptability,
not the legal meaning of conforming to a
set of standards and requirements to be
acceptable.
● Wrongdoer - is the party who initiated the
wrongdoing, directly intending the specific
evil.​
● Cooperator- is involved with the
wrongdoing by means of some action that
is distinct from the evil act initiated by the
wrongdoer.​​​
● Scandal- is when your actions or words
create a temptation to sin for others.
● Proximate vs. Remote Cooperation
- The moral proximity to evil is a
measure of how contingent or
mediate the cooperation would be
to the evil. In other words, how
much does the cooperator’s action
contribute to the action? The closer
the cooperation with the evil, the
more likely the act is to cause evil
results. Remote cooperation is
preferable to proximate
cooperation.
What is Cooperation?
- In the ethically significant sense, it is
defined as the participation of one agent in
 the activity of another agent to produce a
particular effect or share in a joint activity.
TYPES OF COOPERATION
1. Formal Cooperation
● Identification with the purpose
● Directly intend the evil action
● The object of the act or motive of
the agent is evil in nature
● Illicit and absolute evil
● Anyone involved is formally
cooperating in an evil act
● Ex. Bank robbery, abortion
✓Does the act
✓ Agrees
✓ Advice
✓ Counsel
Example: Carly wanted to abort her baby before
leaving for abroad and her friend agrees and
advises her to take Mifeprex (common abortion
pills).
2. Material Cooperation
● You cooperated in the act but not
in the purpose
● Indirectly intend the evil action
A. Immediate
● If one cooperates in an evil act by
performing something that is
essential for the performance of
the evil action.
● Example: A robber pointed a gun
at your head and ordered you to
drive the car and assist in loading
the stolen object
B. Mediate
● if one cooperates in an accidental
or nonessential manner in the evil
action
● Licit and there is no ethical
justification
● Example: Selling weapons that are
later used for homicide
CRITERIA FOR JUDGING THE MORALITY OF
COOPERATION
1. Every cooperation which directly
influences the evil intention of the
person with whom one cooperates, is
always illicit.
➔ It is a scandal to incite others to do
evil and should never be done
2. Formal cooperation is always illicit.
➔ The reason: cooperation not only
affects the evil act but it also
affects the will intention by
approving the mode of action
3. Simple material cooperation is also
illicit. One must not help anyone to do
evil.
➔ Nevertheless, in certain specific
circumstances it may be licit to
cooperate materially in order to
obtain the necessary good or to
avoid a more serious harm
➔ Example: Even if the robbers
pointed a gun at your head, you
should have not helped them but
only if they already harmed you in
a way so that the evil act will not be
complete. One solution could be
just giving the car to the robbers or
calling the police while driving.
EXAMPLE OF CASES
1. General Hospital vs Abortion Clinic
● GH: Only those who were involved
in completing the abortion
procedure is formally cooperating
● AC: All employees are formally
cooperating because even from the
start they have the knowledge that
is an abortion clinic
2. RH law
● Nurses who advise patients to use
contraceptives are formally
cooperating
● Patients who accepted
contraceptives but did not use it
are in material cooperation
3. Abortion
✓ Mother
✓ OB
✓ Anesthesiologist
✓ Cardiologist
✓ Scrub nurse
✓ Nurse aid
✓ Administrator
CASE: An unmarried woman attempted abortion
because her boyfriend did not want to marry her.
In her attempt she was bleeding profusely, and
her relatives rushed her to the hospital. The
doctors completed the procedure.
● Not ethical
● Unmarried woman: Formal Cooperation
● Boyfriend:Immediate Material Cooperation
● Doctors: Material Cooperation and licit
because they did complete the abortion
itself however their goal was to save the
woman’s life

PRINCIPLE OF COMMON GOOD AND

SUBSIDIARY
1. Common Good
- standards of moral values that is
the most suitable or ideal
- This principle allows us to know the
best alternative or option to take in
decision making
- It helps us examine the problem
with a positive outlook since we are
looking for a common goal that will
eventually benefit us
- It involves all the members of a
group or society to achieve the
common goal

Example:
When we do our community health teaching for
the families. The nursing care plan that is being
made by the community health nurses should
coordinate and provide the best care possible for
the whole community. If there are problems with
the nursing care plan, it will affect everyone since
the needs were not addressed properly. Solidarity
plays a role because this will help us in finding a
solution to the problem together.

2. Subsidiarity
- Concerned with the power that is
given to the minority or lowest level
of authority, that issues and
problems should be taken or
handled at local level possible
rather than highest authority
- This guarantees independence for
the lower authority in relation to the
highest authority
Example:
The doctor prescribes a medication to a patient
and lets the nurse do that. The nurse knows that
the patient is allergic to the said medication and
so consults with the doctor. The nurse also knows
what is right and wrong for the patient.