Ethics in Health Services and Policy

A Global Approach

Dean M. Harris

• Publisher: Jossey-Bass
• Year: 2011
• Print ISBN: 9780470531068
• eBook ISBN: 9780470940679
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

This comprehensive textbook analyzes the ethical issues of health and health care in global perspective. Ideal for students of public health, medicine, nursing and allied health professions, public policy, and ethics, the book helps students in all these areas to develop important competencies in their chosen fields. Applying a comparative, or multicultural, approach, the book compares different perspectives on ethical issues in various countries and cultures, such as informed consent, withholding or withdrawing treatment, physician-assisted suicide, reproductive health issues, research with human subjects, the right to health care, rationing of limited resources, and health system reform. Applying a transnational, or cross-border, approach, the book analyzes ethical issues that arise from the movement of patients and health professionals across national borders, such as medical tourism and transplant tourism, ethical obligations to provide care for undocumented aliens, and the "brain drain" of health professionals from developing countries.

Comprehensive in scope, the book includes selected readings which provide diverse perspectives of people from different countries and cultures in their own words. Each chapter contains an introductory section centered on a specific topic and explores the different ways in which the topic is viewed around the globe.

Ethics in Health Services and Policy is designed to promote student participation and offers methods of activity-based learning, including factual scenarios for analysis and discussion of specific ethical issues.

Chapter One

Ethical Theories and Bioethics in a Global Perspective

Learning Objectives

• Acquire proficiency in analyzing the major theories of ethics, such as utilitarianism, and be able to apply those theories to health (bioethics).
• Understand and be able to explain the recent trend in bioethics of moving beyond clinical issues of the doctor-patient relationship to broader issues of social justice and population health.
• Learn how to evaluate whether traditional theories of ethics are truly global and whether there are any universal values that transcend culture.
• Learn how to evaluate whether theories of ethics are useful in helping individuals and organizations in the health system to do the right thing. Begin to debate the best ways of encouraging desirable conduct.

Ethics has been defined in many different ways. According to Tom Beauchamp and James Childress (1994), ethics refers to “various ways of understanding and examining the moral life” (p. 4). Ethics is sometimes referred to as “moral philosophy,” and can also be defined as a system for distinguishing right conduct from wrong (Blocker, 1986, p. 7). “Ethics, in other words, is a theoretical discipline within the broader study of philosophy which attempts to discover why any action is right or wrong; that is, what makes an action right or wrong” (Blocker, p. 8). As a practical matter, what difference does it make if we know why a particular action is right or wrong? The answer is that we want to be able to extrapolate or generalize from the particular situation, in order to develop ways to determine what is right or wrong in other situations.

Bioethics is the application of ethical principles and processes to health, including, but not limited to, health services, systems, policies, and technologies. In the latter half of the twentieth century, bioethics in the United States focused on clinical issues of the doctor-patient relationship, rather than issues of social justice or population health (Marshall and Koenig, 2004, p. 254). During that period the role of the physician became less paternalistic than it had been, and bioethics emphasized the principle of patient autonomy, as expressed in concepts such as informed consent and the right to refuse treatment (Brock, 2000, pp. 21–22). In contrast, the recent trend in bioethics in the United States and many other countries is to move beyond the individual patient and the medical relationship and to address the broader issues of health disparities, public health, allocation of limited resources, and social determinants of health (Marshall and Koenig, 2004; Brock, 2000; Illingworth and Parmet, 2009). This recent trend reflects a concern for social justice both within individual societies and from a global (or worldwide) perspective. The ethical issues addressed in this book are part of this broader focus and include problems of fairness and population health from the global perspective as well as problems that arise in caring for individual patients in different cultures.

This chapter begins by analyzing theories of ethics, focusing primarily on utilitarianism, Kantian ethics, and the doctrine of prima facie moral duties, which is also known as principlism. These theories of ethics can provide a framework for discussion of specific issues, but they raise two potential problems. First, are these theories of ethics really global—in the sense that they apply to all societies and cultures throughout the world—or is each theory limited to the society and culture in which it was developed? This chapter addresses that question by evaluating whether there are any universal values that transcend culture. Are all systems of ethics cultural? The possible existence of universal values that supersede culture is one of the major themes of this book. This theme is introduced in this chapter and then considered in greater specificity in the chapters on autonomy and informed consent, withdrawal of care, reproductive issues, female genital mutilation, health care rationing, health care reform, and corruption in health systems.

The second potential problem with applying theories of ethics to health care is the question of whether those theories are useful in helping individuals and organizations in the health system to do the right thing. If not, how can we encourage people and organizations to do the right thing? This is another major theme of this book, which will also be considered in the chapters that follow. Finally, the activity at the end of this chapter provides an opportunity to evaluate the usefulness of ethical theories in a specific context, establishing a new hospital in a developing country.

Theories of Ethics

For thousands of years of human experience, people have looked for ways to differentiate right conduct from wrong. Systems have been developed for the purpose of helping individuals to try to make ethical decisions and determine the right thing to do in particular situations. Many people have sought simple rules of decision making that could be used in every situation, such as the Golden Rule of treating others as one would like to be treated, but those simple rules often fail to provide specific guidance in complex circumstances (Shaw and Barry, 1992, pp. 9–10). Therefore the search for methods of identifying the right conduct has led to the development of more complex theories of ethics. Even these more complex theories, however, may be based on attempts to distill a single rule that could be used in every situation. As Bonnie Steinbock and others (2003) have explained, “Traditionally, ethical theories tend to be reductionist; that is, they offer one idea as the key to morality, and attempt to reduce everything to that one idea” (p. 9).

In developing ethical theories, some people have relied on the concept of a social contract as the ultimate source of ethics. Under that approach, morality is based on some type of voluntary agreement. Others have concluded that ethics is based on religion or on the concept of natural law. In his 1963 “Letter from Birmingham Jail,” Martin Luther King Jr. reasoned that ethical conduct is based on natural law, which can supersede unjust human law:

One may well ask, “How can you advocate breaking some laws and obeying others?” The answer is found in the fact that there are two types of laws: there are just laws, and there are unjust laws. […] I would agree with St. Augustine that “An unjust law is no law at all.”

Now, what is the difference between the two? How does one determine when a law is just or unjust? A just law is a man-made code that squares with the moral law, or the law of God. An unjust law is a code that is out of harmony with the moral law. To put it in the terms of St. Thomas Aquinas, an unjust law is a human law that is not rooted in eternal and natural law. Any law that uplifts human personality is just. Any law that degrades human personality is unjust. All segregation statutes are unjust because segregation distorts the soul and damages the personality…[King, 1963].

Under this approach an action is ethical if it is consistent with natural law. The way we know the action is consistent with natural law is that it has the effect of uplifting human personality.

However, all of these possible sources of ethics pose problems for the practical matter of applying ethics. If the source of ethics is religion or divine will, that would seem to imply that believers in different religions could have very different standards of ethical conduct. Moreover, how could we expect those who believe in a minority religion, or no religion at all, to follow ethical standards derived from the religion followed by the majority in their society?

If the source of ethics is natural law and natural law can supersede unjust human law, every individual could decide not to obey those human laws that he or she considers to be unfair. That approach would seem to give people the option to make individual decisions about which laws to obey and which laws to violate. Of course we can sympathize with and support civil disobedience against laws that enforce racism and segregation. But what would we conclude about a modern-day Robin Hood who steals from the rich and gives to the poor and who defends the theft by arguing that natural law takes precedence over the unfair human laws of private property?

If the source of ethics is a social contract, what are the terms of that contract? Who agreed to that contract on our behalf? Moreover, contracts involve mutual obligations among all parties to the contract. If an individual has failed to meet his or her obligations to society under the social contract, would that mean the contract has been breached and society no longer has any obligation to that individual?

Serious problems exist with applying values derived from each of the possible sources of ethics; moreover it is probably impossible for us to reach complete agreement about the underlying source of ethical standards. Nevertheless we can analyze and categorize various ethical theories without having reached agreement on their ultimate source.

A useful method of categorizing ethical theories is to distinguish between consequentialist and nonconsequentialist theories (Shaw and Barry, 1992, p. 57). Consequentialism is the idea that only results determine whether an action is right or wrong, whereas nonconsequentialism is the idea that consequences are not the only thing that matters.

One consequentialist theory is utilitarianism. In focusing solely on the results of an action, utilitarianism holds that an action is right if it results in the greatest good for the greatest number of people (Steinbock and others, 2003, pp. 9–10). It is important to identify both the people who would be helped by a proposed course of action and the people who would be harmed by it. This process of identification is similar to performing a stakeholder analysis. That is only the starting point, however. Merely counting the numbers of people who would be helped or harmed would be an oversimplification of utilitarianism. In determining the greatest good for the greatest number of people, utilitarians also consider the degree of benefit or harm to each person, and not merely the absolute numbers of people who are benefited or harmed. Utilitarianism can be contrasted with egoism, which is another consequentialist theory but which holds that an action is right if it results in the greatest good for the only person who really matters—that one individual! (Shaw and Barry, 1992, pp. 57–58).

As stated earlier, nonconsequentialists argue that ethics do not depend solely on results. Nonconsequentialist theories of ethics are also referred to as deontological theories (Beauchamp and Childress, 1994, p. 56). One of the most important theories in this category is Kantian ethics, named for Immanuel Kant, a German philosopher and professor who lived from 1724 to 1804. As a nonconsequentialist, Kant believed that an action might be wrong even if it results in good consequences, and therefore that “the ends do not justify the means” (Steinbock and others, 2003, p. 14). Kant argued that a proposed action would be ethical if it is an action that we would want everyone to perform in a similar situation. In other words, could we “consistently will” that under a particular set of circumstances everyone else should act in that manner? (Steinbock and others, pp. 9, 15). This concept of Kant's is called the categorical imperative. In addition, Kant believed that individuals should be treated as ends, and not as a means to an end, or at least not only as a means to an end (Beauchamp and Childress, 1994, p. 58).

Another approach to ethics is principlism, so called because it is based on a set of ethical principles, including autonomy, justice, and beneficence (Beauchamp and others, 2008, p. 22). Sometimes the principle of beneficence is broken down into separate principles of beneficence, or helping other people, and nonmaleficence, or not harming people. In contrast to monistic theories, such as utilitarianism or Kantian ethics, which try to reduce ethical conduct to a single idea, principlism is pluralistic, in the sense that more than one ethical principle may apply in a particular situation (Beauchamp and Childress, 1994, p. 100; Steinbock and others, 2003, pp. 9, 36–37). The moral duties represented by those principles are not absolute but rather apply prima facie, or at first glance (Beauchamp and Childress, pp. 100, 104; Steinbock and others, p. 37). In other words, one moral duty might outweigh another in the circumstances of a particular case. “A prima facie duty, then, is always right and binding, all other things being equal; it is conditional on not being overridden or outweighed by competing moral demands” (Beauchamp and others, 2008, p. 27). According to the proponents of principlism, prima facie moral duties are based on “common-morality theory” and “shared moral beliefs” (Beauchamp and Childress, 1994, p. 100). “A common-morality theory takes its basic premises directly from the morality shared in common by the members of a society—that is, unphilosophical common sense and tradition” (Beauchamp and Childress, p. 100). (The next section of this chapter addresses the question of whether ethical principles that are derived from the shared beliefs of society can be truly global and universal.)

Which of these ethical approaches, if any, is the best one? Steinbock and others (2003) argue against selecting one theory or approach as the exclusive answer to all ethical questions: “In a typical introduction to ethical theory class, each theory is presented and subjected to devastating criticism. The unfortunate result is that students frequently conclude that all of the theories are wrong—or worse, are pretentious nonsense We conclude that it is a mistake to view the various theoretical alternatives as mutually exclusive claims to moral truth. Instead, we should view them as important but partial contributions to a comprehensive, although necessarily fragmented, moral vision” (p. 9). Steinbock and colleagues are correct that no single theory has conclusively demonstrated its correctness and applicability in all situations. However, that seems to leave us with a “buffet approach” to ethical theory. Individuals are left to say to themselves, “I will look over the menu of ethical theories, and then choose some of each. Perhaps, I will take an order of utilitarianism, with a side order of principlism.” In addition to causing uncertainty, this buffet approach would allow individuals simply to make their own decisions and then to justify whatever they have already chosen to do. How, if at all, would this individualized buffet approach help people to make difficult ethical decisions in the real world of health policy and services?

Throughout this book we will consider the various ethical theories described in this chapter. In particular we will consider two fundamental questions: (1) are these ethical theories really global, in the sense of being applicable to all societies and cultures; and (2) are these ethical theories really useful in helping individuals and organizations to make the hard decisions in the real world of health policy, health services, and global health? Then, if these ethical theories are not really useful, how can we encourage individuals and organizations in the health system to do the right thing?

Are Theories of Ethics Global?

It is beyond dispute that people of different cultures will perceive the same things in different ways and make very different decisions when faced with the same circumstances. For example, as discussed in Chapter EIGHT (about allocation of resources), the Akamba people of Kenya have preferences for rationing limited health care resources on the basis of age that are very different from the preferences of most people in the United States (Kilner, 1984, p. 19). It is also clear that different cultures have different values, or at least that they place very different priorities on particular values. Although Western societies generally place a high priority on individual autonomy and equality, some other societies place their high priorities on values such as solidarity of the community, fulfillment of duty, or obedience to a hierarchical order. As Blackhall and others (2001) have written, “Beliefs commonly held in the European-American culture about individuality, self-determination, and the importance of maintaining control too often have been treated as if they were universal ethical principles” (p. 70).

Does this mean that there is no common morality of ethical principles, one that is shared by all human beings, regardless of the society in which they live? Does it mean that there are no universal ethical values that transcend the values of any particular culture? Those two questions are not necessarily the same. As discussed previously, Beauchamp and Childress, who are well-known proponents of principlism, have argued that the prima facie moral duties are based on “common-morality theory” and “shared moral beliefs” (1994, p. 100). It is difficult to conclude, however, that the moral duties of justice and autonomy are really shared by those societies that do not believe in self-determination for women, equal rights f...

Table of contents

• Cover
• Titlepage
• Copyright
• Dedication
• The Author
• Acknowledgments
• Chapter One: Ethical Theories and Bioethics in a Global Perspective
• Chapter Two: Autonomy and Informed Consent in Global Perspective
• Chapter Three: Withholding or Withdrawing Treatment and Physician-Assisted Suicide
• Chapter Four: Ethical Issues in Reproductive Health
• Chapter Five: Ethical Issues of Female Genital Mutilation
• Chapter Six: Ethical Issues of Research with Human Subjects
• Chapter Seven: The Right to Health Care and Ethical Obligations to Provide Care
• Chapter Eight: Ethical Issues in Rationing and Allocation of Limited Resources
• Chapter Nine: Ethical Issues of Health Insurance and Health System Reform
• Chapter Ten: Ethical Issues in the Movement of Patients Across National Borders
• Chapter Eleven: Ethical Issues in the Movement of Health Care Professionals Across National Borders
• Chapter Twelve: Corruption and Informal Payments in Health Systems
• References
• Index