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 testyou 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. Rosss 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 casefor 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
Philips 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 couldnt 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 cant afford that, she
said sadly. Im a receptionist, and my husband lost his job and just cant 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.
Thats 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 20s. 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 husbandboth loving, caring,
responsible peoplenot have the chance to be parents as well? Preston when on to explain
that, to respond to situations like the Rubins, 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, Tommys 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 Tommys 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. Sanchezs 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 hell 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 Im not sure its certain that hell 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. Sanchezs 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
Presidents 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, well 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 dont know, the Secretary responded. Isnt anyone else worried that opponents will accuse
us of giving too much power over peoples 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 publicordinary citizensinvolved in the decision about what counts as
adequate. After all, theyre the ones who have to live with the consequences!
Again, what about . . . Jake started to say.
Monica interrupted him: I know, Jakethe costs. But consider this: doctors may be experts
about what treatments lead to what outcomes. But you dont 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 Secretarys challengei.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)