Introduction to Ethics in Health Care

Fall, 2012

Final Exam Study Guide The Final will have two sections. In Section I you will provide definitions and brief explanations of important moral concepts or theories (“moral ideas”) covered during the term. In Section II you will use some of these ideas to analyze, and defend judgments about, two hypothetical cases. You may bring 2 pages of notes (8.5x11 sheet, both sides) to the exam; you will turn in your notes with your test. I STRONGLY recommend that you DO NOT use your page of notes to try to write out full answers to the questions in advance. Rather, you should do a brief outline of your answers. That is, for each task listed above, write a few bullet points that summarize your response. I will provide you with paper on which to write your test—you do NOT need a blue book. Section I (60 points) A. Moral theories. Select TWO of the following theories. Explain how each defines right and

wrong in general. Then give an example of a health care situation (you may use an example discussed during the course, or create one of your own), and explain of how each supports a judgment that something in that situation is right or wrong. (10 points each) 1. Utilitarianism 2. Kantianism 3. Natural law ethics 4. Ross’s ethics

B. Autonomy

1. Define autonomy, and say for which moral theory autonomy is most important. How does that theory express the idea of autonomy (in terms of the way people must be treated)? (10 points)

2. Explain how the principle of autonomy and the principle of utility can come in conflict. Give an example of a health care situation to illustrate your explanation. (10 points)

C. Distributive justice

1. Define the concept, explaining the basic principle of justice, and why it is that an unequal distribution of some good may or may not be unjust. (10 points)

2. Give two examples where a) an unequal distribution of health care is just, and b) an equal distribution of health care is unjust. Explain your evaluation of each case in terms of the basic principle of justice. (10 points)

Section II (140 points) In this section are cases inspired by the topics of the four units of the class. Each case is followed by a series of questions which ask you for your moral judgment on the situation, and your analysis in terms of relevant moral ideas. Note, though the cases follow the unit topics in order, they each are designed to raise issues from across the entire semester. Thus, you may use ideas introduced in any unit to analyze any case—for example, you may use ideas introduced in Unit 4 to analyze the first case. You must write about a total of TWO cases (each case is worth 70 points). Unit 1 – Ethical issues in health care practice Responding to a 911 call, EMT medics found Sam Funston slumped over in a park. A man who identified himself as Brother Philip was next to him, praying. Brother Philip insisted on accompanying Funston to the emergency room at the City Hospital, saying that Funston was a member of his congregation and had relied on him to heal him through faith. Doctors examining Funston found that he had internal injuries, and determined that he would die within a day or two if they did not operate. But they were confident that the operation would save his life, and that he had an excellent chance at a full recovery. Since Funston was indigent (and uninsured) the costs of the operation would have to be absorbed by the hospital, and ultimately passed on to the rest of society. Brother Philip insisted that they not do the procedure, because Funston had told him explicitly that he rejected conventional medicine, and wanted to rely on prayer alone. Brother Philip said that he would cover the costs of admitting Funston into the hospital just in order to keep him comfortable, but would not pay anything if the doctors performed any treatment for his condition. In the meantime, hospital staff found that Funston was known to the police as a street person with no fixed address, and who had no friends or family. He had a reputation for being generally cheerful. The police simply did not know whether Funston had spent time in Brother Philip’s mission. But they did say that Brother Philip was known as a sincere and caring man. 1. In your judgment, should the hospital perform the operation on Funston (Option 1) or not

perform the operation (Option 2)? 2. How could someone argue FOR the option you reject? What moral ideas can be used to

support that option? What facts about the situation are most significant in light of those ideas? (30 points)

3. How do you argue for the option you chose? What moral ideas can be used to support that

option? What facts about the situation are most significant in light of those ideas. (30 points) 4. Why do you support the option you chose over the one you reject? Explain why you think,

for this situation, the moral ideas that support your choice are more compelling than the ideas that support the alternative. (10 points)

Unit 2 – Ethical issues in the use of health care services Amy Rubin had never spoken at a public hearing before, so she told her story nervously. “My husband and I wanted to be parents more than anything else,” she said. “We were devastated when my doctor told me we couldn’t conceive naturally.” She went on to describe her visit to the fertility clinic, where she learned that a course of in vitro fertilization, which she had been told was her only hope for becoming pregnant, would cost $15,000. “I can’t afford that,” she said sadly. “I’m a receptionist, and my husband lost his job and just can’t find anything these days.” Although she had insurance through her company, it did not cover IVF. She went on to explain the she had looked into adoption, but the costs involved were almost as much as fertility treatment. “That’s unfortunate,” Nina Preston, the chair of the Insurance Commission said, “but tell us why you contacted me.” “Well,” Amy said, “what really got to me was when I heard about my boss.” She explained that Jenny Harris, the executive she worked for had announced that she had gotten pregnant through IVF. Harris was 46, and had already had three children when she was in her early 20’s. But she had then devoted herself to her career, and had had a tubal ligation as a form of birth control. When her youngest went off to college she decided she wanted another baby in the house. She and her husband, an investment banker, could easily afford to pay for the fertility treatment she received. “To my mind, this is simply unfair,” Preston declared. “No doubt Ms. Harris will be a fine parent this time around. But why should Amy and her husband—both loving, caring, responsible people—not have the chance to be parents as well?” Preston when on to explain that, to respond to situations like the Rubin’s, she was proposing that the state Insurance Commission impose a mandate that private insurance companies cover fertility services, with a provision for a state subsidy to help cover the costs. “I understand that this means that everyone will pay a bit more for coverage,” she said, “but that is a small price to pay to keep fertility treatment from being a privilege of the rich.” 1. In your judgment, should the Commission adopt the proposal (Option 1) or reject the

proposal (Option 2)? 2. How could someone argue FOR the option you reject? What moral ideas can be used to

support that option? What facts about the situation are most significant in light of those ideas? (30 points)

3. How do you argue for the option you chose? What moral ideas can be used to support that

option? What facts about the situation are most significant in light of those ideas. (30 points) 4. Why do you support the option you chose over the one you reject? Explain why you think,

for this situation, the moral ideas that support your choice are more compelling than the ideas that support the alternative. (10 points)

Unit 3 – Ethical issues in medical research Tommy Trasker had an amazing fastball. Even as an eighth grader he was attracting attention for his pitching, and he and his parents, Jim and Suzi, were already planning for a future in baseball. They were counting on his skills to get him a college scholarship, and they could easily imagine him playing in the major leagues. Jim and Suzi were understandably distraught when they learned that Tommy had been hit by a car while biking home from school. Though he got up and walked away, the shoulder of his pitching arm was definitely injured. The Traskers took Tommy to see Cynthia Towers, a physical therapist with long experience of working with athletes, who said that he would not benefit from surgery, but rather should undergo physical therapy. But after two months, Tommy’s shoulder was still too sore for him to practice pitching. They returned to Towers, who told them about Dr. Ruben Sanchez, a researcher at the University Medical Center nearby. Dr. Sanchez was conducting research on a new procedure for repairing joints involving sophisticated electronic implants and drugs, which work together to help the nerves stimulate muscle fiber. The therapy was highly experimental. It had shown some good results in laboratory tests, but had not been tried on anyone with Tommy’s precise condition. And, when used for other purposes the drugs had been shown to have the potential to cause long-term damage to the nervous system, inhibiting its ability to transmit signals. But Dr. Sanchez believed that he understood how to prevent these side effects. And he was extremely eager to test his treatment on Tommy, because he believed that what he would learn from working on him would contribute toward making the treatment safe and effective for thousands of young athletes. The Traskers met with both Dr. Sanchez and Cynthia Towers to decide whether Tommy should enroll as a subject in Dr. Sanchez’s study. Dr. Sanchez explained the risks of the treatment, concluding by saying “Yes, there is some risk that the treatment will not enable Tommy to play baseball again. But if he does not do the treatment it is certain that he’ll never play. At least the treatment gives him some chance at getting back in the game.” The Traskers turned to Towers for her opinion. “Well I’m not sure it’s certain that he’ll never play if he just sticks with physical therapy. But forget about baseball. I just worry about the risks for his overall health if he does the treatment.” Jim and Suzi Trasker looked at each other, and then at Tommy. “What do you want, honey?” his mother asked. He looked in her eyes and said, “I just want to throw my fastball.” 1. In your judgment, should Tommy participate in Dr. Sanchez’s study (Option 1) or not

(Option 2)? 2. How could someone argue FOR the option you reject? What moral ideas can be used to

support that option? What facts about the situation are most significant in light of those ideas? (30 points)

3. How do you argue for the option you chose? What moral ideas can be used to support that

option? What facts about the situation are most significant in light of those ideas. (30 points) 4. Why do you support the option you chose over the one you reject? Explain why you think,

for this situation, the moral ideas that support your choice are more compelling than the ideas that support the alternative. (10 points)

Unit 4 – Ethical issues in the provision of health care The Secretary of the Department of Health and Human Services called the meeting of her advisors to order. “We now have the legal authority to set the standards for the level of health care to which all US citizens are entitled,” she started. “In line with the views proposed by the President’s Commission on Health Care years ago, I reject the idea that the standard should be that everyone receives the same amount of health care, or receives any health care they might benefit from. Instead, we’ll go with the principle that everyone is entitled to adequate health care.” “Sounds fine, chief, except . . . “ As usual, Jake Chen was about to raise a tricky point. “Except what, Jake?” the Secretary asked. “Well, what do you mean by adequate, exactly?” Jake responded. “The commission admitted that what counts as adequate would vary according to circumstances. So how are we supposed to give concrete guidance to insurance companies? What has to get covered, and what counts as more than adequate?” The Secretary turned to her advisors, asking “Any ideas?” Tricia Klein raised her hand. She had practiced internal medicine, and her opinion was widely respected. “I think this is at bottom a medical question,” she declared. “I think we get doctors together, and provide them with the best data about outcomes for various treatments. In a word, panels of medical experts are best equipped to determine what levels of treatment will keep people healthy.” “But what about costs?” Jake interjected. “Same answer,” Tricia replied. “Medical panels have the knowledge required to weigh treatment outcomes against costs, and to decide what mix of health care services should be available given a certain overall health care budget.” “I don’t know,” the Secretary responded. “Isn’t anyone else worried that opponents will accuse us of giving too much power over people’s lives to these medical panels?” “I am!” It was Monica Lewis, who had trained as a sociologist. “I think it is crucial to get members of the public—ordinary citizens—involved in the decision about what counts as adequate. After all, they’re the ones who have to live with the consequences!” “Again, what about . . .” Jake started to say. Monica interrupted him: “I know, Jake—the costs. But consider this: doctors may be experts about what treatments lead to what outcomes. But you don’t have to be an expert to know whether an outcome is worthwhile. Ordinary folks can make that judgment, so they are perfectly qualified to make trade-offs between outcomes in order to keep to a budget.” “OK,” the Secretary said. “So what do we do?” 1. Which moral ideas does Tricia appeal to in her proposal? (20 points) 2. Which moral ideas does Monica appeal to in her proposal? (20 points) 3. How would you respond to the Secretary’s challenge—i.e. how do you think what counts as

adequate health care should be determined? Support your answer in terms of moral ideas from the course. (30 points)