Week 1-1 abortion

Population-level bioethics course

- Analysis of normative propositions (sentences with normative concepts)
- Deductive method
- Conceptual analysis – concept of personhood in Tooley’s paper
- Thought experiment – what is our intuition in this case? Eg Thompson’s paper
- Compare intuitions and concepts for consistency.
- Thought experiment presents a parallel case that controls variables to neutralize our
tainted intuition.
The focal point of abortion debate
1. It is wrong to kill a person
2. A fetus is a person
3. Therefore, it is wrong to kill a fetus
- Thomson ⎼ Even if we concede that a fetus is a person, abortion is morally permissible
- Tooley ⎼ If abortion is morally permissible, infanticide must also be morally permissible

1-2 abortion
Thomson’s thought experiments
(1) The violinist case ⎼
Intuition: It is morally permissible for you to unplug yourself from the violinist ⎼
Analysis: The violinist’s right to life does not give the violinist a right to your body ⎼
Conclusion: It is morally permissible for you to terminate the pregnancy (non-consensual)

“An organism possesses a serious right to life only if it possesses the concept of a self as a
continuing subject of experiences and other mental states, and believes that it is in itself
such as continuing entity.

Tooley’s argument
1. There is no morally relevant difference between fetus and newborn infant
2. If it is permissible to destroy a fetus, then it must also be permissible to destroy a
newborn baby
3. It is permissible to destroy fetus and newborn baby because these do not meet the
requirement

Week 2-1 euthanasia

Passive voluntary -> Active voluntary Rachels’s example
• The doctrine of acts and omissions
⎼ There is a morally relevant difference
• Rachels (Tooley’s symmetry)
⎼ There is no difference
1. Smith drowns his young cousin in the bathtub
2. Jones finds his young cousin already unconscious under water and refrains from saving
him.

Active voluntary -> Active non-voluntary

1. Below the level worth continuing to live
2. The lack of capacity to express consent
⎼ People with severe dementia?
⎼ Newborn baby with severe disability (infanticide case)?
⎼ Pressure on patients (financial, emotional, social, etc)

Informed consent?
• Belgium: The request from the patient is the necessary and practically sufficient condition
for lethal injection by physician.
⎼ Very young, mentally impaired, demented, under duress or constraint, etc.
• Presumed autonomy
⎼ The foundation of contemporary medical practice
• Overriding cases
⎼ Quarantine and compulsory hospitalization
• Hard cases
⎼ Blood-transfusion against a patient’s will
⎼ Ian McEwan’s The Children Act

Week 2-2 Genetic screening/enhancement

Genetic screening
• Preventive intervention from genetic test (uncontroversial)
⎼ E.g., Defective BRCA1 gene
• Preimplantation genetic diagnosis (PGD) (IVF – reasonably uncontroversial)
• Noninvasive prenatal blood test (NIPT) and amniotic fluid test (AFT) (controversial)
⎼ Trisomy 21 (down syndrome), trisomy 13 (won’t survive), trisomy 18 (won’t survive),
neural tube defects, and more
⎼ Abortion after trisomy 21 diagnosis: UK (90%), Denmark (98%), France (77%), US (67%),
Canada (90%).
⎼ Quebec: the cost of AFT is covered if pregnant woman requests a test.
⎼ England and Wales: all pregnant women are tested from 2004
Discussion: “If the publicly-funded health care system covers the cost of prenatal screening,
knowingly that most of pregnant women choose to terminate a pregnancy. That is the same
as subsidizing discrimination against persons with disability” (women’s rights vs disability
rights vs human rights) (need to justify the rights)
Eugenics
“Improving” the genetic quality of a population
⎼ Nazi holocausts
⎼ USA: Indiana Eugenics Law (1907) and 32 States
⎼ Canada: Alberta Sexual Sterilization Act (1928); BC Sexual Sterilization Act (1933);
residential schools
⎼ Isolation of the leprosy patients in Japan until 1996
Jeff McMahan on the wrongness of having a child with disability
1. It is wrong to cause an already born child to become disabled
2. It is wrong to cause a future child to be disabled through the infliction of prenatal injury
3. Therefore, it is wrong to cause a disabled child to exist.
Response: Disability is not a loss in any respect of QoL (the mere difference view)
Savulescu’s case for the duty of enhancement (transhumanism)
1. “Neglectful Parents”
⎼ The child has a stunning intellect but requires a supplement to sustain his intellect.
⎼ Parents neglect the diet of this child and the child becomes normal.
⎼ This is wrong.
2. “Lazy Parents”
⎼ A child with a normal intellect
⎼ If parents give the dietary supplement, the child’s intellect would rise to the stunning level
as the child of the Neglectful Parent.
⎼ The inaction of the Lazy Parents is as wrong as the inaction of the Neglectful Parents.
Usually treatment is publicly funded, enhancement (cosmetic surgery etc) is not

Week 3-1 Necessity of health care rationing

Gender inequality is a population-level bioethics issue: (females live longer on average -> no
biological reason but due to lifestyle)
Canada’s population 39 million (2022)
World population 7,162 million (2022)
• Canada male/female: 19,365K / 19,668K
• World male/female: 3,609M / 3,665M?
• Actual male/female: 3,609M / 3,551M
114 million women are missing in the world!
• “Missing women” (excess death)

Sreenivasan’s case for rationing approach

1. Health is not the only good.
2. The limit on justifiable health care spending is independent of the aggregate cost of
medically necessary services.
3. The reverse-engineered approach exposes society to the danger that its health care
budget will exceed the limit on justifiable health care spending, and hence will violate
justice.

• Finance
⎼ Health insurance (public or private)
⎼ Government funding
⎼ Co-payment
• Delivery
⎼ Public
⎼ Private

3-2 Human rights to health

The WHO definition (1946): • “The enjoyment of the highest attainable standard of health is
one of the fundamental rights of every human being without distinction of race, religion,
political belief, economic or social condition.”

To what level?
• All health care needs (inc. cosmetic surgery)?
• All pathologies?
• The life expectancy of Japanese women (e.g., global burden of disease studies)?
• Minimal level of health?
• Easily preventable causes of premature deaths?
To whom?
• To any particular individual?
• To the state/government?
• To international community?

Sreenivasan
• Very poor states do not bear the moral duties correlative to human claim-rights to health.
• There is a problem of global distributive justice, but not the human right to health.
• The human right to health against the state requires too much.

Hausman
• The human right to minimally good life
• The human right to the minimal level of health ⎼ Not much of expansive health care)

Rationing and human rights

• Rationing limits the access to health care.
• The appeal to human right to health/health care does not solve the scarcity of health care
resource
• The appeal to human right to health merely ends up with the conflict of human right.

6-2 Responsibility of luck

Three approaches to responsibility in health

1. Luck egalitarianism (e.g., Shlomi Segall)

2. Fair equality of opportunity (e.g., Daniels, Kennedy, Kawachi)

3. The health-only framework (e.g., QALY-based health care rationing)

Luck egalitarianism:
– tries to neutralise the differential effect of brute luck
Option luck – Something that you had a choice over (something you can control), (losing a
bet on horse-racing)
Brute luck – Out of everyone’s control (family you are born into)
Hard to draw border line between option luck and brute luck
What is the point of egalitarian justice?
⎼ To neutralize the differential effects of brute luck.
⎼ Not be concerned with differential effects of option luck.
• It is bad if some people are worse off than others through no fault or choice of their own.
⎼ Shlomi Segall. Health, Luck, and Justice. Princeton University Press, 2010
• The harshness (abandonment) objection – not providing healthcare (letting them die) is
unjustifiably harsh in response to the actions

Fair equality of opportunity:

• Health, and therefore, health care, is special
⎼ The specialness thesis (health forms basis for everything else in life)
• Health inequalities deprives the worse off persons of pursing their life/goal and creates
unfair inequality of well-being.
• Therefore, health inequalities must be reduced.
⎼ Responsibility does not play any role in the allocation of health care resource
People should pay cost somewhere else other than hospital (eg. Higher tax rates on tobacco
products, alcohol), doesn’t cover many cases (illegal drugs, dangerous sports (skateboarding)
etc)

Social determinants of health:

• Is it fair to hold smokers responsible?
⎼ Correlation between health outcome and socio-economic status
⎼ Correlation between health risk and socio-economic status
• What is “socio-economic status”?
⎼ The “upstream/downstream” distinction, upstream is further from actual health condition
(correlations)
eg. Neighbourhood -> plumber -> smoking -> high blood pressure -> cancer

Social gradient of health

• Daniels, et al: “Justice is good for population health”.
⎼ Health status is not transferable.
⎼ It is possible to reduce health inequalities through redistribution of socially controllable
determinants of health such as income and the opportunities for education, employment,
housing, etc. (redistribution of income would have more effect than spending more on pure
healthcare)
• Angus Deaton
⎼ Casual directions
⎼ Education

A fundamental philosophical question

• Can we hold anyone responsible?
• Free will debate ⎼ Determinism (human can’t be held morally responsible for their actions,
no free will) – compatibilism (some free will to some extent) – libertarianism (everything is a
choice, 100% responsible for everything)

Case C: hard to measure health benefit, very expensive

Are we arguing whether or not we can ethically justify a government refusing an expensive
treatment for autism due to it being extremely expensive despite showing promise? (and
possibly being these kids best hope at having the ‘greatest possible opportunities in life’
(therefore improving wellbeing) eg. without discriminating against people with disabilities?

Or are we arguing whether or not it is ethically right to provide this treatment?