[CLSA] 1
PRE-FINALS
ASM 4: INTRO TO HEALTH CARE ETHICS
Practical Wisdom
• An approach to ethical reasoning that not only examines
actions and their consequences but also
→ Questions why we understand particular events to
be significant at all
→ Why this action or result is important for humans
→ “What is ethical is not legal, what is legal is not
ethical”
• When we say actions are good or right, how do we explain
what this means and why we are correct?
• Theory – principles which attempt to describe the truth
about reason and reality
Emotions and Ethical Life
• Emotions – influence our ability to perceive ethical values
and make ethical judgements
• Practical ethics → emotions color our perception of world
& inform our judgements of actions in that world
→ Commitment to others is emotional as well as
intellectual
• Human nature and ethics
→ True subject matter of ethics is human nature,
its core, and limits
→ Basic questions raised in health care ethics:
informed consent, professionalism, just
distribution, death, enhancement (genetic/not)
▪ Require meditation on human ethics for
answers
• Ethics – branch of philosophy that seeks to determine how
human actions may be judged as right or wrong
→ Judgement from nature of reason or experience
→ Philosophical ethics not same as religious ethics
THEORIES OF ETHICS --------------------------------------------------
• Theories about characteristics of human activity
• Ethical dilemma – arises when individual or society faces
choices of actions w/c are completely different, even
completely opposite, yet seemingly each end can be fully
justified by an ethical theory
Consequentialism
• Sees the rightness and wrongness of an action in terms of
the consequences brought about by that action
→ Evaluated by how much action serves some
intrinsic good (independent of consequences)
• Utilitarianism or social consequentialism
→ One should act so as to do the greatest good for
the greatest number
→ Greatest good by J.S. Mill – presence of pleasure
and absence of pain (best choice yields greatest
amount of preferred pleasure and least pain)
• Ethical analysis of contraception (utilitarian look)
→ From perspective of concerns of individual or society
→ Society: good if perceive growth as burden (mouth to
feed) or bad if population growth is encouraged
→ Individual: good if pleasure of sexual activity without
commitments to raising a child is wanted
▪ Contraception itself not good or bad but
acquires its value because of larger end
• Problems
→ Unlikely that high quality pleasure is deep good
→ Idea that consequences are external to actions that
brought them about
→ Overlook good of individuals in favor of majority
Kantian Deontologism (Immanuel Kant)
• The idea that an act can be described as good and what ought to
be done because it expresses certain characteristics such as
universality or conformity with the moral law
→ If maxim/statement of action could be universalized
as appropriate for everyone, action is ethical
→ Formal rules used in judging act
→ Lying is wrong even if end is greater good because it
involves disrespecting who you are lying to
• Duty – demand for action that respects dignity of others
• Dignity of individual – fundamental equality of all persons,
need to protect equality with rights
• Places more emphasis on individual, disregards community
• Contraception – in this view is wrong because sexual activity
for sake of pleasure violates the obligation to never use a
person (partner) simply as means
→ Acceptable if in context of marriage or abiding
commitment to partner (respected as person)
Natural Law
• Rational reflection on (human) nature will yield principles of
good and bad that can guide human action toward human
fulfilment or flourishing (actualization of potential)
• Focuses on ability to recognize structured complexity and
coherence of nature (study of nature and its definitions)
→ Difficult because definitions of natural realities
(marriage, family, etc.) can be subject to dispute
→ What was once thought to be natural has been shown
to be social (dominion of master over slave)
• Like utilitarianism and Deontologism, assumes that we can
reason ourselves out of problems via formal criterion or
definition of nature that denies role of consequences
• This view condemns contraception as unethical
→ Believe that there is natural order that identifies
procreative consequences of sexual activity as key
purpose of that activity
→ Allowing pleasure without consequent reproduction
subverts the natural order
→ Unaffected by concerns of individual or society

Virtue Ethics
• Systematic formulation of traits of character that make
human praiseworthy or blameworthy
• Broadly defined involves integration of virtues with what
has been called practical wisdom or right reason
→ Consider emotional disposition and cultural
background (training of virtues of society)
→ Development of reason to balance emotion
• Practical wisdom – ability to choose patterns of action
made/revealed to be desirable by reasoning
→ Primary virtue for ethical decision making
→ Reasoning informed by habits of emotional
experience, considering its widest possible range
→ Grows from ability of additional experience to
enrich or alter our intuitions (product of previous
experience and training)
• Contraception neither good or bad and must be evaluated
by looking at particular circumstances at issue w/ regards to
→ Those involved
→ Social history of the practice
→ Practical consequences for indiv & society
Key Issues
• Dignity of individual
• Role of society
• Moral ambiguity, opacity, limits of practical wisdom
→ When matter truly opaque, society turns to law
• Society and moral and legal rights
• Public or common good
• Tragic in human life
PRE-FINALS
ASM 6: BENEFICENCE & MALEFICENCE
BENEFICENCE -------------------------------------------------------------
• Impossible to do good and avoid bad all the time
→ Nature and time of space (everywhere at once)
→ Limited by talents
→ Limited by the state of art (5th pinky)
→ Obligation to avoid evil (can’t save someone
drowning if you cannot swim)
▪ Nearly everything we do has some
undesirable side effect/risk of evil
→ No escape from all risk (adverse rxn of meds)
• Specifications of beneficence
→ Necessary for humanity and dignity
▪ Nourishment, shelter, clothing
▪ Those only desirable comes 2 nd
▪ Situations of conflict (how can
humanity of 1 person > another?)
▪ Forgo medical care to avoid
impoverishing family
→ Societal obligations
▪ Most goods we have to do are specified
by social agreements (laws, custom)
[CLSA] 2
▪ How society distributes resources is
expression of what it thinks of as good or
necessary
SPECIFICATIONS OF NON-MALEFICENCE ---------------------
• Primum non nocere – “first, do no harm”
• Problem is recognizing what is harm
Principle of Double Effect
• Developed by natural law thinkers, most famous
• Person may perform act that has or risks evils if all four
conditions are verified
→ Action is good and morally indifferent
→ Intend the good effect, not evil effect
→ Evil effect cannot be a means to good
→ Proportionality between effects
• Pursuing treatment for cervical cancer while pregnant is
acceptable (satisfies all four)
• Treatment for ectopic pregnancy violates steps 1,2,3
Principle of Proportionality
• Provided that action does not go directly against dignity of
individual (intrinsic good), there must be proportionate good to
justify permitting or risking evil effect
• Not consequentialist, priority to dignity of individual
• Proportionality judged by four factors
→ Alternative ways of attaining intended good w
▪ Smallest amount of evil possible
▪ Drugs for HTN – not using drug w/
harmful side effects if tx possible w/ diet or
exercise
→ Level of good intended & level of risk permitted
▪ Not all goods and evils are equal
▪ Some things merely useful for human life,
some are necessary
→ Certitude of good or evil
▪ Some serious evils remote or v. small risks
▪ Everything has risk, choose less or act
against more sure evil
▪ Balance levels of good/evil with probability
→ Causal influence of agent
▪ Most effects from many causes
▪ In many cases, no causal influence and no
possibility for person to change situation →
no obligation to remove or avoid evil
▪ Minor contributor to evil needs less good to
justify actions (cleaning staff vs. board of
directors on overcharging hospital patients)
Preliminary Summary
• Avoid evil and evil consequences unless you have
proportionate reason for risking or permitting them
• Do good unless consequences of doing food produce
disproportionate evil

OBLIGATIONS -------------------------------------------------------------
Patient’s Obligation
• Individuals obliged to use ordinary but not extraordinary
means of preserving and restoring their health
→ Ordinary – more harm than good
→ Extraordinary – more evil than good
• Take care of health as long as, all things considered, this
does not produce more harm than good
→ “All things considered” – distinguishes patient’s
obligation from health care professional &
surrogate
→ Health care professional not expert on quality of
life
• Patient must make health decisions in context of
obligations to family, society (legal right to refuse
treatment ≠ ethical right)
Health Care Providers Obligation
• Medical indications principle – granted informed consent,
physician should do what is medically indicated
→ From medical point of view result good > evil
→ Medical benefits outweigh medical burden
→ Competent in this given area
• Medical professionals judge proportionality of
consequences
→ Medical or nursing indications
→ Operation not advised for those about to die, not
indicated for those where operation does not have
good chance of treatment, indicated if good
chance
Surrogate’s Obligation
• Substituted judgement principle – surrogate acts in
accordance to wishes of patient if wishes of once
competent patient are known orally or in writing
→ Overruling wishes is violation of person’s
autonomy
→ Problem: often surrogates do not know wishes of
patient even when they think they do
• 2 principles for when patient has never been competent or
competent but never manifested their wishes
→ Best interest principle – surrogate act in
patient’s best interest disregarding others
▪ Huge loans for continuing medical care
→ Rational choice principle – surrogate choose
what patient would have chosen when competent
and after considering all available relevant info
and interests of relevant others
▪ Surrogate should not be family
▪ You cannot be your family’s doctor
ISSUES ------------------------------------------------------------------------
• Quality of life
→ Quality of life judgement has different status
when there is judgment about value and meaning
of life
[CLSA] 3
→ Medical professionals cannot make quality-of-life
decisions about relative worth of person (cannot
judge if life no longer worth living)
→ Different values, meaning of life
→ Scarcity of resources – talk about rationality of
choices (advice but never decide for them)
• Professional power and benevolence
→ Ethical obligations that arise from unequal power
relationship between patient and health care provider
(job convenience vs. patient’s comfort)
→ Ideally, all principles observed – caregiver
overcomes all annoyances from patient
→ Common abuses of power
▪ Physician says he will not treat patients if
he hears they go to another doctor
▪ Doctor makes patients wait for him instead
of him waiting for them and thus wastes
their time
▪ Nurse punishing disobeying patient by
answering call bell 20 minutes later
▪ Nurse putting family member outside of
room because they make her nervous when
taking patient’s BP
• Medical indications & unnecessary surgeries
→ Second opinion in case procedure is unnecessary
→ Avoid saying anything bad about colleague
• Conflicts of interest
→ Subordination of patients interest to interest of a third
party (physician owns pharmacy business)
→ AMA declared it unethical for physician to refer px
to facility where doctor has financial interest, unless
px is informed
• Health care provider as patients advocate
→ Does not authorize professional to overrule patients
or lawful surrogates but it does when everything else
has been done
→ Authorize or even oblige them to seek court
protection for patient when abuse suspected
• Beneficence and right to refuse patients
→ Except in emergencies
→ Stories of indigent patients “dumped”
→ Physician’s role calls for charitable work, not for
becoming charitable institution
→ Legitimate reasons to reject some patients
▪ Lack of skills
▪ Lack of time
▪ Legally and ethically can be guilty of
abandonment when not continuing
treatment will expose patient to danger
▪ Termination require provision of continuity
of care to qualified personnel
SUMMARY -------------------------------------------------------------------
• Impossible to do all good and avoid all evil
• Necessary to have principles that specify which good are to be
provided (involves judgment of proportionality)

• Medical indications principle is a prime example of
principle of proportionality and professional obligation
joined in 1 principle
• Quality of life issues are not our expertise
• Patient should not be turned away except for relevant
reasons and if ever, there should be continuity of care
PRE-FINALS
ASM 7: PRINCIPLES OF CONFIDENTIALITY
& TRUTHFULNESS
Ben and Mary went to doctor to seek help with inability to have
child. After 2 months of management, Mary got pregnant. On 3 rd
month of consultation, doctor reads laboratory report sent late that
Ben is sterile. Will you inform Ben he is sterile?
• Any social relationship depends on truthful
communication, but telling everything could → disaster
→ Telling whole truth ≠ telling whole truth
→ Some truths should be kept confidential
→ Difficult to decide what may be ethically
concealed and what must be revealed
▪ Tell wife that husband has AIDS?
▪ Inform that fiancé has herpes?
▪ Conceal that daughter had abortion?
TRUTHFULNESS -----------------------------------------------------------
• Ordinary ethics
→ Do not lie (if you communicate, do not lie)
▪ Free not to communicate, evade
falsehood by staying silent ≠ lie
→ Must communicate to who have right to the truth
▪ Question of who has right to
communication of the truth
→ These are hypothetical “commands”
• Lie = not telling the truth, speech against the mind
→ Communicating something which is at odds with
what speaker believed to be true
→ Understood to be wrong
→ Revised definition of lying – examination of
nature and range of reasonable expectations
→ Falsehood in circumstances in which other has
reasonable expectation of truth
Expectations
• Connected to obligation of confidentiality and right to
privacy
• Three factors that determine reasonableness of expectation
of truth, part specifications of obligation to minimize evil
and justify evil by proportional good
• (1) Place of communication
→ Not reasonable if place where other people can
overhear conversation
→ Doctor may withhold info from patient of his
illness until in privacy of clinic (not cafeteria)
[CLSA] 4
• (2) Roles of communicators
→ Types: doctor, patient, relative, public
→ Doctor must choose what truth or may withhold truth
depending on who they are talking to
→ In counselling, relationship is confidential and
obligation to confidentiality changes expectations
→ Doctor, in doing history of px, has reasonable
expectations of truthful answers bearing diagnosis
→ Patient who goes to doctor for consultation has
reasonable expectations to be told the truth
→ When people have no reasonable expectation to the
truth, doctor has right to conceal truth and protect
privacy of self and others
▪ Not lie to conceal truth but may be
unethical for other reasons
▪ If one shuts up to evade telling truth, not lie
▪ Difference between being asked and
volunteering information
→ People do not ordinarily have reasonable
expectations that health care provider will tell them
truth about anyone but themselves
→ Volunteering info – no one asked, creates reasonable
expectation of truth
→ Health care workers who use media to spread
medical news must be accurate, give full disclosure,
enjoy editorial independence
▪ Independence necessary to void conflict of
interest that might result from dependence
on drug company / censorship by an editor
• (3) Nature of truth involved
Right to Truth
• Informed consent
• Px has right to truthful info because he paid for it (precise info
that he is paying for)
• Patient has right to know even if no informed consent and no
explicit purchase of information
• Pater asks doctor of prognosis of his stage 4 cancer. Should
doctor inform him or withhold information?
→ Peter has right to truth so he can plan out what to do
for the remaining time he is alive
→ According to religious thinkers, denial of truth mocks
dignity of person
Placebo Problem
• Placebo – “sugar pill ; look-alike” pill that has no
pharmacologic effect that is given for psychological effect, or
as a control in research evaluating efficacy of a study drug
• Drugs with active pharmacological properties have enhanced
effects because patients believe in them
• Hawthorne effect – in industrial psychology, merely paying
attention to workers increases productivity and cooperation
• Placebo has been found to have effect in immune system and
even produce addiction
• Effect of drugs depend not only on their pharmacologic
properties but mental set of user and setting drug was taken

• None of these justify use of placebo except in highly
restricted circumstances
→ Although effect may make important
contributions to patient care, physician must not
rely on that effect
Is it correct to prescribe herbal medication that did not undergo
thorough study and clinical trial regarding safety for use & efficacy?
• If physician says, “I am going to prescribe something that
often helps and so far has no reported bad side effects”
→ Physician deemed not lying
→ Patient knows what he needs to know to make
decision as no untruth was spoken and no
information was suppressed
• When placebo is overpriced and used in place of standard
treatment, failure to use accepted treatment when called for
is called malpractice
→ Overpricing condemned as form of theft
Summary of Truthfulness
• It is wrong to tell falsehoods in situations in which there is
reasonable expectation of the truth
• Expectation of truth varies according to place of
communication, roles of communicators, and nature of
material being communicated
CONFIDENTIALITY ------------------------------------------------------
• Concerned with matter of keeping secrets
• Secret – info that person has right or obligation to conceal
Rey was diagnosed to have AIDS. His wife does not know.
• Divulging info depends on circumstances
• If wife is no longer of child bearing age where there is no
risk to infect their future children or of childbearing age
and wants to have child
• In deciding to divulge information, it is important to assess
impact of withholding truth to society
→ Will withholding truth put society at risk?
• Obligation to keep secrets arises from fact that harm will
follow if particular secret is revealed
Mario was diagnosed to have AIDS. He is about to marry Grace who
is strictly conservative and has had no premarital sex with Mario.
Divulge info to Grace?
Types of Obligatory Secret
• Types will distinguish harmful consequences that will
result from revelation
• (1) Natural secret
→ Info involved is by its nature harmful if revealed
→ Universal obligation to “do no harm”
→ Even friend of px who has AIDS will not divulge
the information
→ We are obliged to keep secret peculiarities of px
that will cause him embarrassment if revealed
[CLSA] 5
→ If harm from concealing natural secret outweighs
harm that is being avoided, revealing is justifiable
→ Roy who has AIDS insisted donating blood to Red
Cross despite you trying to convince him not to. Will
you divulge information to Red Cross?
• (2) Promised secret
→ Knowledge that we have promised to conceal
→ Special evil of revealing promised secret arises from
harmful effects of breaking promises
→ Most become wary of persons who break promise
→ Like natural secret, there may be proportionate
reasons for revealing secret
▪ Good to be obtained must offset evil that
results from broken promises
→ James asks physician to promise to keep secret. After
he promised, he says that he has purchased a gun
and intends to use it to kill students and his hated
teacher in school. Will you warn authorities?
• (3) Professional secret
→ If revealed, will harm not only the professional’s
client but will do serious harm to profession and
society that depends on profession for important
services (keep for good of profession and society)
→ Privileged information – physician cannot disclose
info learned in confidence from patient unless patient
gives permission
→ Most serious of all secrets, violation → greatest harm
→ In America, when law passed obliging health
professionals to report all minors with STDs to
parents, minors no longer went to seek consult for
STD. Result was epidemic of STDs.
Stakeholders That Need Information
• Third party players
→ Health insurance – need access to diagnosis and
treatment of patient
→ Billing office – will need to go through work ups
done and has access to patient’s records
Confidentiality and Consultation
• Referrals to other health professionals
• Discussing px’s case in case conferences
• Residents, interns, students in teaching hospital not free to read
px’s chart unless directly involved in care of particular patient
• Exceptions arise from unusual relationships
→ Occur with family and military personnel who owe
loyalty to their employer as well as patient
→ As long as px understands that they are not fully
protected by confidentiality, there is no serious
ethical problem
• Special cases
→ Media and publicity and confidentiality
→ Children and adolescence
→ Hospital records, research, and confidentiality