Ethical Health Care
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Ethical Health Care

Patricia Illingworth

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Ethical Health Care

Patricia Illingworth

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Offering a format that is significantly different than that offered by other books, Ethical Health Care beings by asking what is meant by health and how it is achieved. The book then proceeds to explore with care and context the nature of the relationship between patients and clinicians, health care providers and the societies in which they inhabit, and finally the relationship between the health care enterprise and the international community. By emphasizing the ethical issues that arise in the broad quest to foster human health, and appreciating that health is not primarily a function of medical interventions, Ethical Health Care introduces students to problems such as the international distribution of pharmaceuticals and the dangers of reemerging infections. To a far greater extent than is done traditionally, Ethical Health Care provides an interdisciplinary perspective to bioethics, relying heavily upon the teachings of economics, law, and public health.

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Chapter One

Expanding Our Horizons

A. Shifting Paradigms

Concern about the social and ethical implications of health care practices and biomedical advances is everywhere. From discussions about partial-birth abortion to debates about stem cell research, one cannot escape controversies about the moral quandaries that arise at the forefront of modern medicine. In this book we will explore these traditional bioethical issues as well as some new ones. We will do so in a manner that is different from (and we hope more fruitful than) the approaches typically taken.
Until now, discussions about the ethical implications of health care have typically taken place from a vantage point that emphasizes the role of individual health care providers and their relationship to individual patients. These discussions, framed within the paradigm known as bioethics, generally isolate the relationship between health care providers, especially physicians, and patients—separating them from the institutions, communities, and social contexts in which they interact. Not only does this isolation give patients and providers a false sense of control over patient welfare, it fails to portray realistically the nature and complexity of the dilemmas that arise within the health care context. For in fact, the issues bioethicists have traditionally analyzed are far more complex and far more connected to larger, social forces than is generally acknowledged. Moreover, the health of individuals—which is after all the goal of medical care—is far more dependent upon the wellbeing of the community in which they reside than traditional bioethical discussions acknowledge. In other words, the health of individuals is at least partially dependent on the health of communities, thus falling within the purview of public health.
In recent years, bioethics as a discipline has attempted to respond to these concerns by broadening its reach and working more closely with other disciplines—particularly law, medicine, and religion. Nonetheless, bioethical inquiry has remained, for the most part, focused on individuals. The ethical issues that arise when we consider the health of communities, and the relationship between individual health decisions and social forces, remain largely unintegrated into the discourse, creating a false divide between the health interests of individuals and that of the public, between bioethics and social justice. The results, all too often, are policies that optimize neither the health of individuals nor the well-being of their communities.
If our discussions about health care and ethics are to inform our policies and strongly support the health and freedom of all individuals and communities, we need to widen the debate and transform the paradigm. Bioethical issues must include the topics and perspectives that are typically relegated to discussions of public health, health economics, social policy, and the law. In turn, those social issues must be enriched by the understandings and discussions typically conducted by bioethics. In other words, population-based considerations must be included in the bioethics dialogue.
To begin this task of broadening the debate and redefining bioethics we need to reexamine the assumptions upon which the discipline of bioethics has been predicated. We must look also to other disciplines—particularly public health with its emphasis upon population well-being—to consider different perspectives. And, as we reexamine the issues that confront both bioethics and public health, we must remember to include the insights garnered from the other disciplines. Most important, at each step of the journey, we must continue the dialogue and engage more voices in the quest for human health and well-being.

B. The Bioethical Perspective

The discipline of bioethics developed in the late twentieth century. As with the earlier field of medical ethics, its primary focus has been on the doctor–patient relationship. But bioethics differs from traditional medical ethics, with its emphasis on developing norms for physicians, by looking at questions that arise outside of the clinical context (such as questions relating to research) and adapting a wider interdisciplinary perspective. In this respect bioethics has pioneered interdisciplinary work. Until quite recently, it has drawn most often from philosophical ethics, principles of justice, case law, and Judeo-Christian religious perspectives. Given the interdisciplinary bent of bioethics, the task of incorporating an even broader public-health perspective should not be a daunting one. The current crisis that health care faces between, on the one hand, improving access to care and, on the other hand, stemming the ever rising cost of care may be just what is needed to facilitate this shift.
Following contemporary Anglo-American philosophy, which emphasizes solving problems, such as the mind–body problem or skepticism about the external world, bioethics has focused on concrete problems. This approach can also be traced to the nature of medicine and the queries that are raised by physicians. Physicians work within the parameters of the human body and their goal is to cure specific illnesses. Faced with an ethical problem, in a dialogue with a bioethicist, physicians bring their expertise in medicine to the discussion and ethicists bring their knowledge of the normative world. Following the paradigm of practical ethics, ethicists then apply the principles and theories of a long philosophical tradition to complex medical fact patterns. Early in the history of bioethics, the discussions between physicians and “philosophical enthusiasts” often resembled “turf wars” in which the focus of the debate was over what part of the issue was medical and within the physician’s expertise, and what part normative and within the purview of the ethicist.
To understand the ethical perspectives used by bioethicists, we need to know some of the key characteristics of ethical judgments. First, the ethical judgments with which we will be concerned are about people and our interaction with them. Some scholars also believe that bioethics should include within its scope nonhuman animals. Although we agree in principle, space considerations make it impossible for us to address this important topic in this volume. Second, ethics usually concerns conduct. That is, when we make ethical judgments we are usually evaluating actions. Third, ethical judgments are typically universal. An ethical judgment that is true for one person in a particular situation is also true for anyone else in the same situation. If it is wrong for your friend to break a promise made to a dying relative, it is also wrong for you to do likewise. Thus the ethical point of view is strongly committed to impartiality. Fourth, ethics is prescriptive. Ethical judgments are concerned not only with describing conduct but also modifying it and prescribing action.
Bioethicists use ethical theories and principles as tools to help them identify and resolve ethical dilemmas. Because these theories figure prominently in traditional bioethics and will appear in some of the readings we include in this volume, it is important for us to review some of them. Applied ethics draws on several kinds of theories. Most prominent are deontological and teleological theories. Deontological theories focus on actions and whether or not they conform to a rule. If the question at hand is “Should I tell this patient the truth about her cancer or should I lie?” the deontologist is interested in determining whether or not there is a rule prohibiting deception, and, of course, there is. Indeed, lying is considered morally wrong by almost all ethical systems.
Typically, rights theories are viewed as deontological. People with rights can make a legitimate claim on others to either provide them with something (a positive right) or to refrain from interfering with them (a negative right). In either case, others incur a corresponding duty to the rights’ holder. For a rights theorist, the morally relevant question is, “Does this particular conduct violate a right?” If it does, then it is considered unethical. Ronald Dworkin, an important contemporary rights theorist, calls rights “trumps.”1 Put differently, when someone holds a right, that right trumps all considerations of utility.
Perhaps the most significant deontological moral theory to be used in contemporary bioethics is that of Immanuel Kant. Kant was an influential eighteenth-century German philosopher. Most of his important work on ethics appeared in a short volume entitled Foundations of the Metaphysics of Morals, which was published in 1786.2 Kant, unlike John Stuart Mill and the utilitarians, did not believe that the morality of an action can be found in its consequences. Instead, he believed that the moral worth of an action could be determined by looking at whether the action conformed to moral law, a universally valid maxim of action. To ensure that the maxim that serves as the basis of action is in concert with the dictates of morality, Kant believed that the actor should determine if his or her maxim could be universalized. A maxim would qualify as universal, and in turn, as moral law, if a person could will that it apply both to his or her own case and morally similar cases. Kant also referred to the moral law as the categorical imperative. Kant formulated a second version of the categorical imperative, “respect for persons,” that appears widely throughout medical ethics. According to Kant, we ought to “treat every person as an end and never solely as a means.”3 When we treat people as ends in themselves and not as means to ends, ours or anyone else, we treat them with respect and dignity.
Finally, for Kant, an agent’s intentions are also morally important. Agents who act for the sake of duty are morally praiseworthy whereas those who act to achieve some end or their own self-interest do not act morally. In this respect the dictates of morality are categorical; they are not optional. Critics to the Kantian approach object to its absolutism on the grounds that it fails to be responsive to the factual intricacies of context.
Teleological moral theories regard the consequences of actions as morally important. To find out whether or not an action is morally right, teleological theories look not at the action itself, but at what the action produces. Utilitarianism is a specific kind of teleology that asks people to evaluate the consequences of actions on the basis of whether or not these actions maximize the general happiness. John Stuart Mill articulated the general happiness principle, according to which we have an obligation to maximize the general happiness,4 each to count for one and none to count for more than one.5 By insisting that no one count for more than one, utilitarianism introduces impartiality into the utilitarian calculation since it requires that no one’s interests, including those of the person doing the calculation, count as more important than the interests of any other person. Mill defined happiness as “pleasure and the absence of pain.”6 Some contemporary utilitarians, called preference utilitarians, think that happiness should be identified with preference satisfaction.7
Although utilitarianism is a powerful and useful theory in bioethics, it has been associated with a number of problems. In its singular pursuit of the total greatest amount of happiness, utilitarianism appears to ignore basic human rights. If, for example, a utilitarian calculates that the general happiness would be best served by killing several homeless people for the purpose of harvesting their organs for the benefit of other socially worthwhile people, then the theory would seem to implore us to do just that. But not only is it morally counterintuitive to kill innocent people for the benefit of others, to do so involves a violation of the right to be left alone.
Yet, sometimes, utilitarianism is charged with being too morally demanding. In one formulation, known as Act Utilitarianism (AU) it requires us to maximize happiness each and every time we act. If, for example, we find that we have $100 available to spend, utilitarians require us to use the funds to maximize the general happiness. Instead of spending the money on our own pleasure or that of our family and friends, perhaps dinner and a movie, the utilitarian calculus would probably ask us to donate the money to relief of suffering in the developing world.8 Surely, it is unrealistic to think that people could ever meet such an exacting moral standard.
Finally, utilitarianism is complicated. It requires people to make complex calculations about the long-and short-term consequences of actions and their alternatives. This can be not only intellectually challenging, but also time consuming. Many ethical decisions, including those that arise in a health care context, must be made quickly and under conditions of uncertainty about the consequences of one’s actions. The emergency room (ER) leaves little time for elaborate calculations!
Utilitarians respond to these objections with an important modification to the theory. According to rule utilitarianism (RU), utilitarians can use utilitarian calculations to establish rules. They reason that certain rules can safely be adopted because the probabilities are that they will maximize the general happiness. More often than not, utility will be maximized if we tell the truth. Use of rules will decrease the disutility caused by errors in calculations. It allows us to sidestep egregious and counterintuitive violations to human rights because chances are we would have a rule against, for example, killing the innocent. It does not require agents to make complicated calculations because they would simply have to refer to the rules. Finally, it does not demand sainthood. Instead of always having to maximize happiness, rule utilitarians...