MEDF1021 Public Health and Healthcare Ethics Lecture Notes PDF

MEDF1021 Public Health and Healthcare Ethics Ethics: An overview to biomedical ethics Prof. Roger Chung JC School of Public Health & Primary Care The Chinese University of H...

MEDF1021 Public Health and Healthcare Ethics Ethics: An overview to biomedical ethics Prof. Roger Chung JC School of Public Health & Primary Care The Chinese University of Hong Kong September 25, 2024 2024 Roger Y Chung, CUHK  Lecture Objectives To describe the relevance of ethics to public health and healthcare To describe bioethics and public health ethics To describe the basic bioethical approaches, including theories and principles To describe the basic fundamentals of how bioethical principles work To describe the general principles in biomedical ethics 2024 Roger Y Chung, CUHK  What is Ethics? 2024 Roger Y Chung, CUHK  What is ethics? Ethics – A set of principles, rules, values and ideals of a particular group of people (in its descriptive sense); i.e., what is right or wrong? – Systematic study of moral concepts and theories (a philosophy discipline); aka. Moral philosophy 2024 Roger Y Chung, CUHK  What is Philosophy? 2024 Roger Y Chung, CUHK  What is Philosophy? “Philosophy is not so much about coming up with the answers to fundamental questions as it is about the process of trying to find these answers, using reasoning rather than accepting without question conventional views or traditional authority.” “The Philosophy Book” DK 2011 2024 Roger Y Chung, CUHK  What is ethics? 2024 Roger Y Chung, CUHK  What is ethics? Ethics (moral philosophy) studies and considers what is good and bad conduct, right and wrong values, good and evil – Dichotomous or continuous? Primary investigations: – How to live a good life? – Identify standards of morality 2024 Roger Y Chung, CUHK  What is ethics? First order ethics → Normative ethics – Is it right/wrong to do something? – What is morally right/wrong? Second order ethics → Meta-ethics – What is the principle behind the decision of doing right/wrong? – What makes the action right/wrong? 2024 Roger Y Chung, CUHK  What is Bioethics? 2024 Roger Y Chung, CUHK  Bioethics as applied ethics Concerned with the analysis of particular moral issues in private or public life – Bioethics: Correct approach to moral issues in the life sciences (e.g. euthanasia, allocation of scarce health resources, use of human embryos/animals in research) Bioethics is cross-disciplinary, and not confined to medical professional perspective (broader than medical ethics) 3 main cores: – Medical/clinical ethics – Research ethics – Public health ethics 2024 Roger Y Chung, CUHK  Applied Ethics of Biomedical Sciences Medical/clinical ethics (醫學／臨床倫理) – Concerns issues related to practice of medicine – Focus: Doctor-patient relationship/Clinical decisions/Patient’s autonomy/Informed consent/Abortion/Reproductive ethics/Pediatric ethics/Geriatric ethics/Surrogate decision making/Advance directives/Euthanasia and assisted dying/Organ transplant/Healthcare rationing, etc. Individuals more than population Research ethics (研究倫理) – Focus: Clinical trials/Big data/Consent/Misconduct/Authorship/Integrity/Research subjects/Research design/Justice, etc. Public health ethics (公共衛生倫理) – Seeks to understand the factors that influence people’s health – Finds ways to improve people’s health as a population – Focus: Public health regulations/laws/policies often involves trade-offs between public goods and private interests Collective benefits of population health vs. personal and economic interests Public health laws and policies/Distribution of health care/Global health/Health equity/Social determinants of health, etc. 2024 Roger Y Chung, CUHK  Moral Dilemma 倫理衝突 2024 Roger Y Chung, CUHK  Trolleyology: Scenario 1 2024 Roger Y Chung, CUHK  Trolleyology: Modified Scenario 1 2024 Roger Y Chung, CUHK  Modified Trolleyology: Healthcare Setting, Scenario 1 You: Doctor 6 injured: 5 moderately injured (they would die if not being take care of) and 1 severely injured (would die if not being taken care of) 2024 Roger Y Chung, CUHK  Trolleyology: Scenario 2 2024 Roger Y Chung, CUHK  Trolleyology: Modified Scenario 2 2024 Roger Y Chung, CUHK  Modified Trolleyology: Healthcare Setting, Scenario 2 You: Transplant surgeon 5 patients desperately in need of 5 different organs No organ donor 1 healthy patient waiting for a checkup in the next room 2024 Roger Y Chung, CUHK  2 Major Types of Moral Theories Consequentialism (結果主義) – the right/wrong of action based on the values of their consequences; e.g. utilitarianism Kantian Deontology (義務論) – Morality grounded in reasoned duties that command categorically Both theories are based on only ONE SINGLE PRCINIPLE! 2024 Roger Y Chung, CUHK  What are moral theories? 2024 Roger Y Chung, CUHK  Moral theory Moral Theory attempts to provide systemic answers to very general moral questions about: What to do How to be 2024 Roger Y Chung, CUHK Copyright © 2017. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong Moral theories and their purpose Seek to establish in systematic fashion, at the general abstract level, what makes some actions ethically right (and possibly obligatory, praiseworthy, etc.) and others wrong (forbidden, etc.) As opposed to ethical evaluation of specific practices: e.g. abortion, assisted dying, the death penalty, meat-eating… – Which falls within scope of applied, as distinct from normative, ethics 2024 Roger Y Chung, CUHK 2  Level of abstraction in ethics: from Moral Theories to Principles, Rules, and Judgments More abstract Moral Theories 道德理論 E.g. Utilitarianism, Deontology, Virtue Ethics, Care Ethics, Principlism… Mid-Level Ethical Principles 倫理原則 E.g. Principlism: respect patient’s autonomy, do no harm, do good, do justly … Specific Moral Rules 倫理規則 More E.g. Laws, regulations, protocols (governing actual practice): do not kill, do not cause specific pain/suffering, do not cause offense… Specific considered E.g. Specific case: Good death vs. marginally judgments 具體倫理判斷 prolonging his life (based on judgments, 2023 Roger Y. Chung, CUHK intuitions, experience, etc.) 2024 Roger Y Chung, CUHK  Aims of moral theory Practical Aim Decision procedure whose use by suitably informed agents will reliably lead them to the correct moral verdicts about matters of moral concern Theoretical Aim Discover the underlying morally salient features of actions, persons, and other items of moral evaluation that make them right or wrong, good or bad. Both aims work together for the process of moral reasoning to function 2024 Roger Y Chung, CUHK  Moral principles Fulfill both theoretical and practical aims of moral theory by: 1. Specifying underlying features that make something right or wrong 2. Allowing suitably informed agents to guide moral deliberation and choice 2024 Roger Y Chung, CUHK  Major moral theories 2024 Roger Y Chung, CUHK  Major moral theories Pre-theory: Religion and traditions Stick to the doctrine: depending on the interpretation of religious texts 2024 Roger Y Chung, CUHK  Major moral theories Traditional Western monistic moral theories (i.e., theories basing on 1 principle alone) Consequentialism (Utilitarianism) Outcome-oriented: Maximize the good outcome, minimize the bad outcome of the action (i.e., maximize the net utility/benefits) Categorical deontology Action-oriented: Can the action itself be universally applied or considered as categorically correct? Virtue ethics Influenced by religion Agent-centered: Do what a virtuous person would do Better yet, cultivate your own virtues so you can do the right thing Sentimentalism (not a complete theory) Emotion/sentiment drives action, not reasoning per se 2024 Roger Y Chung, CUHK 2024 Roger Y Chung, CUHK  Major moral theories Recent critiques of the traditional theories and developments Care ethics (still monistic) Influenced by virtue ethics Agent-centered: Do what a caring person would do The dawn of feminine ethics as another perspective → gave rise to feminist ethics later 2024 Roger Y Chung, CUHK  Limitations of monistic theories Most of the controversial moral conflicts CANNOT be solved by one single foundational principle! There are many perspectives in this world → pluralistic world No one person is purely utilitarian all the time, or purely deontologist all the time, or purely sentimental all the time… Focusing on the battles among the different moral theories as foundations is missing the point! 2024 Roger Y Chung, CUHK  Major moral theories Recent critiques of the traditional theories and developments Care ethics (still monistic) Influenced by virtue ethics Agent-centered: Do what a caring person would do The dawn of feminine ethics as another perspective → gave rise to feminist ethics later Principlism (pluralistic) 4 principles that matter the most for health/healthcare Need to balance the specified principles in actual situations to arrive at a moral verdict Narrative ethics (not a complete theory, but a different perspective/approach) Listen to people’s stories, concerns, worries, limitations, reasons behind decisions and thoughts Not driven by a deductive framework (i.e., utilitarianism, deontology, virtue ethics, care ethics, or even principlism) Non-Western/Non-mainstream ethics (not a complete theory, but incorporating different perspectives from other cultures/traditions) Check if you’re only thinking from a Western/mainstream perspective Feminist ethics (not a theory, but a pluralistic approach in itself) Approach that incorporates ALL the major moral theories as perspectives! 2024 Roger Y Chung, CUHK  Perspectives matter! No one theory alone can represent this! Care Ethics 2024 Roger Y Chung, CUHK  A feministic ethics approach Sentimentalism Virtue Ethics Care Ethics Utilitarianism Deontology Narrative Ethics Chinese Ethics Principlism 2024 Roger Y Chung, CUHK  Not stacking all lenses! Not checkbox exercise! 2024 Roger Y Chung, CUHK  Major moral theories Pre-theory: Religion and traditions (doctrinal) Traditional Western monistic moral theories (i.e., theories basing on 1 principle alone) Consequentialism (Utilitarianism) Categorical deontology Virtue ethics Sentimentalism (not a complete theory) Recent critiques of the traditional theories and developments Care ethics (still monistic) Principlism (pluralistic: the 4 major principles specifically constructed for health and healthcare) Narrative ethics (not a complete theory, but a different perspective/approach) Non-Western/Non-mainstream ethics (not a complete theory, but incorporating different perspectives from other cultures/traditions) Feminist ethics (not a theory, but a pluralistic approach in itself) 2024 Roger Y Chung, CUHK  Principlism (原則主義) Tom Beauchamp (1939 – ) James Childress (1940 – ) 2024 Roger Y Chung, CUHK  Principlism – Core Concept A pluralist and principalist account of moral norms – a framework of 4 prima facie and equally basic moral principles 1. Respect for Autonomy 2. Non-maleficence 3. Beneficence 4. Justice Prima facie: Must be taken/followed at its face value but is not absolute These are 4 general moral statements that purport to set forth conditions under which an action is right/wrong; or something is good/bad 2024 Roger Y Chung, CUHK  Principlism – Core Concept These 4 principles are derived from a larger set of universal norms (e.g. principles, virtues, rights, particular judgments) supposedly shared by all persons committed to morality (i.e., “common morality”) Like utilitarianism and deontology, principlism is also based on reasoning 2024 Roger Y Chung, CUHK  Principle 1 – Respect for Autonomy A moral norm of respecting and supporting autonomous decisions It does NOT have moral priority over other principles Three conditions – Intentionality (binary) Planned, not by accident – Understanding (gradation) Substantial but not full understanding – Non-control (gradation) Free of control exerted by either external sources or internal states that rob the person of self-directedness Specific to autonomous choices but not respect in general (i.e., decision-specific) 2024 Roger Y Chung, CUHK  Principle 2 – Non-maleficence A moral norm of avoiding the causation of harm At least do no harm! May be more stringent, impartial, and general (to all people) than obligations of beneficence – Do not harmful – Do not cause pain – Do not cause suffering – Do not kill – Etc. Prima facie but NOT absolute: Requires justification of harmful actions “A harm is a thwarting, defeating, or setting back of some party’s interests” but “not always wrong or unjustified” According to Beauchamp and Childress, the criteria that matters is quality of life 2024 Roger Y Chung, CUHK  Principle 3 – Beneficence Moral norms for providing benefits and balancing benefits against risks and costs (including positive prevention and removal of harm, which is different from negative avoidance of harm) For Beauchamp and Childress, common morality does not require beneficence in the form of severe sacrifice and extreme altruism (not supererogatory) Not general to all people, but specific based on relations, agreements, contracts, etc. 2024 Roger Y Chung, CUHK  Principle 4 – Justice Moral norms for fairly distributing benefits, risks, and costs Mainly concerned about distributive justice according to principlism (narrow focus) 2024 Roger Y Chung, CUHK  Formal Principle of Justice The Formal Principle of Justice (aka. The Principle of Formal Equality): “We must treat equals equally, but unequals unequally.” (Aristotle) 2024 Roger Y Chung, CUHK  Principlism – Conception of right action Theory of right conduct: The 4 principles function as general guidelines from which more specific moral rules and conclusions can be derived When these prima facie obligations conflict, the most stringent/weightiest of them overrides the rest to become the “actual obligation” (i.e., all- things-considered obligation) in a particular situation, leaving behind moral residues that are not canceled out/silenced, which gives rise to new moral obligations 2024 Roger Y Chung, CUHK  Principlism – Methods/Analysis: 4-Step Process (Top down) 1. Identify moral norms – The 4 principles, e.g. respect for autonomy Prima Facie obligations 2. Specify norms in context – E.g. Allow competent patients to exercise their liberty rights – E.g. Respect the autonomy of competent patients by following their advance directives when they become incompetent 3. Make balanced judgements – E.g. Balancing between respect for patient’s autonomy and beneficence: A terminally ill cancer patient who had expressed that he did not want CPR if he became unconscious due to his sickness, but had a unrelated accident and his head was hit, and so needed a CPR to resuscitate his life 4. Aim for coherence – Bottom-up: To inform how we specify and Actual obligation + balance the different moral norms → to strike coherence with other judgments of other Moral residue cases (not living in a vacuum) 50 2024 Roger Y Chung, CUHK  Specifications (詳細說明) A process to reduce the indeterminacy of abstract principles and generating rules that can guide action in specific contexts To narrow the scope of the principle To add contents and details – E.g. Respect for autonomy → obtain informed consent from patient about intervention/treatment → physician to disclose the benefits and risks of the treatment to generate adequate level of understanding by the patients There could be different ways to specify the same principle 2024 Roger Y Chung, CUHK  Balancing (平衡) Balancing judgments must meet conditions that ensure “rigorous reasoning” and reduce “intuition” to be justified Conditions that must be met to justify infringing one moral norm to adhere to another norm 1. The moral objective justifying the infringement has a realistic prospect of achievements 2. No morally preferable alternative actions are available 3. The lowest level of infringement (that can achieve the primary goal of action) has been selected 4. All negative effects of the infringement have been minimized 2024 Roger Y Chung, CUHK  Example of balancing Patient group A prefers Treatment X over Treatment Y (respect for autonomy) More vulnerable patient group B may need Treatment X to avert untimely deaths Due to justice, Treatment X may be given to Patient group B despite this is not the autonomous preference of Patient group A Justice in this case overrides the respect of autonomy concern 2024 Roger Y Chung, CUHK  Aim for Coherence Integrate case learning to inform steps 1-3 The ethical decision for this particular case does not exist in vacuum Reflective equilibrium: the principle of concern should be supported by other theories, principles and particular observations (specific considered judgments) 2024 Roger Y Chung, CUHK  Moral residue (道德殘渣) Acknowledging and recognizing that actual obligation does NOT silence other moral considerations What can be done with these moral residues? Notification Public justifications of the infringement of moral considerations Apology Compensations Repair Further works to avoid/ameliorate/prevent the same moral conflict to happen in the future 55 2024 Roger Y Chung, CUHK  Case Study 1 – Vaccine Pass (Public Health) 2024 Roger Y Chung, CUHK  The relevant facts COVID-19 was rampant for over a year COVID-19 vaccines were developed The traditional trial process has not been completed yet, but governments could grant emergency use in face of the pandemic situation Efficacy is 50-80% But there may be severe side effects Government decided to implement Vaccine Pass in many public venues (including schools, restaurants, public facilities, private vendors like clubs, theaters, etc.) in order to maximize the protection against COVID-19 2024 Roger Y Chung, CUHK  Moral Norms Identification (& Specifications) Non-maleficence (vaccine may harm some people with severe side effects) vs Beneficence (vaccine can protect up to 50-80% efficacy from COVID-19) Non-maleficence (vaccine may harm some people with severe side effects) vs Justice (mass vaccine program could protect many people and maximize population health) Respect for autonomy (people’s autonomous decision is compromised due to external control) vs. Non-maleficence (vaccine may harm some people with severe side effects) Respect for autonomy (people’s autonomous decision is compromised due to external control) vs. Beneficence (vaccine can protect up to 50-80% efficacy from COVID-19) Respect for autonomy (people’s autonomous decision is compromised due to external control) vs. Justice (mass vaccine program could protect many people and maximize population health) 2024 Roger Y Chung, CUHK  Balancing Conditions that must be met to justify infringing one moral norm to adhere to another norm 1. The moral objective justifying the infringement has a realistic prospect of achievements 50-80% protection 2. No morally preferable alternative actions are available Vaccine Pass to achieve herd immunity is better than natural selection to achieve herd immunity 3. The lowest level of infringement (that can achieve the primary goal of action) has been selected Vaccine pass is restricted to public venues vs. a vaccine pass that applies to private venues too 4. All negative effects of the infringement have been minimized Private information not disclosed to a degree that the patient is identifiable The infringement on liberty is not to a degree that restricts people from engaging in basic activities 2024 Roger Y Chung, CUHK  Aim for Coherence Particular considered judgment: It is morally permissible to implement Vaccine Pass for greater disease prevention and health protection Principle of concern: It is morally permissible to restrict on individual liberty to strive for greater common good Theory: Utilitarian justice requires the maximization of good for the greatest number of people 2024 Roger Y Chung, CUHK Coherent system  Moral residue (道德殘渣) Remember the moral residues are not silenced, and we need to deal with them! Notification Public justifications of the infringement of moral considerations (i.e., liberty) Apology Compensations Repair Further works to avoid/ameliorate/prevent the same moral conflict to happen in the future 61 2024 Roger Y Chung, CUHK  Principlism – Strengths Powerful and probably necessary attempt to reflect and engage the complexity of moral life, and direct our attention to morally relevant features of a situation Preserves a role for principled/reasoned justification in bioethics that attempts to squeeze out intuition, judgments, sensibilities, emotions, and subjectivity as much as possible Helps unify/systematize our moral judgments Enable ethical reasoning in a deductive framework Specifying and balancing in a coherence model ameliorate noted limitations (e.g. conflicts between principles) Strengths of coherence models: consistent with how we argue ethically; does not privilege certain forms of moral knowledge over others; captures multi-layered and cross-disciplinary nature of moral reflection 2024 Roger Y Chung, CUHK  Principlism – Limitations Principles leave out important features of morality (e.g. why only 4 principles?) Insoluble conflict between principles could still exist → moral residues Balancing may mark the end of reasoned justification as a tool for moral reflection because there are no new reasons given for the balance and seems to rely again back on intuition on particular balance we strike Emphasis on rationalism/consistency comes at potential risk to NOT: – Exploring other forms of moral reflection – Accommodating the full range of credible moral commitments – Focusing on the impact of persons 2024 Roger Y Chung, CUHK  Principlism – Limitations Coherence model has limitations too… 2024 Roger Y Chung, CUHK  Aim for Coherence Specific considered judgment: It is morally permissible to implement Vaccine Pass for greater disease prevention and health protection Principle: It is morally permissible Specific considered to restrict on individual liberty to judgment: We should strive for greater common good respect individual’s liberty at all times, Theory: Utilitarian justice requires even during public the maximization of good for the health emergency greatest number of people 2024 Roger Y Chung, CUHK Coherent system  Principlism – Limitations Coherence model has limitations too… – Back to balancing with intuition and judgment again – What if there is a particular considered judgment, which makes morally intuitive sense, that conflicts with the whole coherent system of theories, principles and judgments? Should we give up the principles or the new particular considered judgment? Should we always aim for coherence? Or should we just let the irreconcilable but important moral commitments stay? 2024 Roger Y Chung, CUHK  Principlism – Relevance to Bioethics The 4 principles of biomedical ethics widely used in healthcare and medical fields today! Probably the most influential contemporary approach to talking about ethics in health and healthcare It considers moral pluralism and offers an approach to deal with moral dilemmas (by specifying and balancing them, albeit with limitations) 2024 Roger Y Chung, CUHK  Is the selection of moral theories only a matter of taste/intuition/tradition? Not necessarily… The two guiding principles to select the moral theory to use are that the moral theory should: 1. Address what we share as humans (e.g. human’s interests, needs, experiences, nature as sociable animals) 2. Not rest on assumptions about the world that are wrong to our current knowledge (e.g. it is ok to murder someone against his/her will) Feminist ethics ask us not to choose before using them, but use them first as different perspectives, and see which one(s) are morally weightier in the specific situation 2024 Roger Y Chung, CUHK  Why do moral theories matter? Are principles enough for our work? 2023 Roger Yat-Nork Chung, CUHK  Straightforward Car Mechanic/ Biology-Medicine Application Model Physics Model Model “The ethical theory is “Cars operate “Bioethics does not the starting point, according to the laws operate and we apply the of physics, to be sure; independently of theory to the case at but one doesn’t have ethical theory … hand in order to to know physics to be [T]here is an interplay reach a conclusion a good mechanic, between theory and about what should be and one certainly case study that done.” (209) doesn’t ‘apply’ the benefits both.” (219) laws of physics to fix cars.” (210) Ref: Rachels, J. (2007). Chapter thirteen. In The legacy of Socrates: Essays in 71 moral philosophy (pp. 209-219). New York: Rowan & Littlefield 2023 Roger Yat-Nork Chung, CUHK  Straightforward Car Mechanic/ Biology-Medicine Application Model Physics Model Model Do what the theory Four principles are We don’t just apply tells you to do … enough. You don’t theory. Theory literally … have to understand informs principles where they come and practice, and E.g. from. Just use them practice informs our Act from duty (Kant) to solve your ethical theory and principles Maximize utility (Mill) problems. E.g. E.g. Clinician-Scientist Respect autonomy 2023 Roger Yat-Nork Chung, CUHK  Key messages – Reflections on Principles and Theories The car mechanic model is limited – theoretical issues pop up everywhere in the work of biomedical ethics But ethical theory is a work in progress – not quite ready to be straightforwardly applied in biomedical ethics Therefore, we need to be able to call on BOTH (biology- medicine model) the resources of ethical theory, and the learning & progress that occurs in practice 2023 Roger Yat-Nork Chung, CUHK  Key messages – Reflections on Principles and Theories Principles have usefulness in the work of biomedical ethics Principles alone are not enough: which principles are valid? Moral Theory can provide higher level reasons and explanations to favor some principles over others, generally or in particular cases 2023 Roger Yat-Nork Chung, CUHK  Thank you! 2024 Roger Y Chung, CUHK