Medicine ethics

1. The last principle, justice, has both a social and political meaning.
Socially, it means, treating similar kinds of people similarly (this is the so-
called “formal element” of the larger principle). A just physician treats
each patient the same, regardless of his insurance coverage.
Politically, the principle refers to distributive justice, and in medicine, to
the allocation of scarce medical resources.
Distributive justice refers broadly to the distribution of all rights and
responsibilities in society, including, for example, civil and political rights.
THE CONCEPT
OF JUSTICE

2. PRINCIPLE
OF
JUSTICE

3. Principle of Justice - It means giving on his due
What is due an individual is determined by
any or all of the following:
1. What he deserves by right, either his natural rights or rights
granted him by law or prior undertakings, independent of
the claims of others (non-comparative justice) example: the
right of life.
2. Balancing of competing claims of other persons against an
individual’s claim according to some morally relevant
property or merit (comparative justice, fairness) example:
giving a donated kidney to the one who needs it most.
3. Acting uprightly in any action bearing on others.

4. It is unjust not to give a person
what is his due. It is equally unjust to
burden or to reward someone for
something that is not his due: for
example to oblige an individual to
be a subject for research which is no
direct benefit to himself.

5. 1. Formal Principle of Justice
As attributed to Aristotle, the formal
principle of justice states that equals
ought to be treated equally and
unequals may be treated unequally

6. 2. Material Principles of Justice
Material principles identify a relevant
property such as need, effort, or
merit as the basis of which burdens
and benefits should be distributed
and excludes other properties as
irrelevant.

7. PARADIGMS OF JUSTICE
Tobin describes 4 paradigms of
Justice as
1. Utilitarian. Justice as whatever brings about the
greatest good of the greatest number.
2. Egalitarian. Justice as the equal distribution of
goods and services
3. Libertarian. Justice as the lack of restraints on
individual liberty.
4. “Natural Law”. Justice as doing to others what one
would have them do to oneself.

8. IMPLICATIONS OF THE PRINCIPLE OF JUSTICE
These implications can be derived from the principle
of justice:
1. Each individual should receive what his due
by right such as:
a. life
b. information needed for decision making
c. confidentiality of private information

9. 2. Benefits should be justly distributed among
individuals such as:
a. minimum health care
b. equal opportunities for a scarce resource
3. Each individual should share in the burden of
health and science such as:
a. caring for his own health
b. caring for the health of others
c. participating in the health/science progress

10. VIOLATIONS OF THE PRINCIPLE OF JUSTICE
The following are the violations of the principles of justice:
1. Denying/withholding a benefit to which a person has a
right. Example: withholding life saving medications
from one who needs them.
2. Distributing a minimum health benefit unequally.
Example: providing selected individuals with available
safe water.
3. Imposing an unfair burden on an individual. Example:
using the underprivileged as research subjects.

11. NON- VIOLATIONS OF THE PRINCIPLE OF
JUSTICE
The following are the non-violations of the principles of justice:
1. The patient chooses to give up what is due.
Example: He asks not to be told of the risks
involved in a recommended treatment.
2. The patient has lost his right to what is due.
Example: Because smokers refuse to care for
their health, they might be considered
responsible for their chronic lung diseases and
lose their right to at least, free health care.

12. 3. The patient chooses to accept an additional
burden. Example: He volunteers to be a
research subject for a study not directly of
benefit to him.
4. When what appears to be an unjust outcome
results from a just process. Example: In a lottery
among all suitable candidates for an available
kidney, the richest candidate wins.

13. ROLE OF THE HEALTH PROFESSIONAL
The health professional can apply the principle of
justice by:
1. In delivering health care give each patient
what is due: the available care he needs,
information and confidentiality.
2. Providing equal health care to all patients
without discrimination.

14. 3. Working towards just health care policies such as
the delivery of minimum health care to all
according to their needs.
4. Avoiding giving undue burden to individuals:
abusing the poor by using them as learning
material.

15. The aspect of justice that pertains to a fair
scheme of distributing society’s benefits and
burdens to its members is termed distributive
justice. In the medical context, the presumed
benefits are receiving medical care and
treatment; the presumed burdens are paying
for care and partaking in experimental
research.
MEANING OF DISTRIBUTIVE JUSTICE

16. PROBLEM OF DISTRIBUTIVE JUSTICE
Macroallocation deals with decision regarding how
much of society’s resources should be used for health
care as distinct from education, infrastructure,
defense, social welfare, etc. The following questions
should be addressed.

17. ✓ What kind of good is healthcare or what kind of ends does it serve?
✓ Should healthcare be regarded just like any other commodity or service or does it have
special features?
✓ Is there a right to some kind of healthcare be given priority over the social goods?
✓ What proportion of community’s resources should be properly devoted to this good and
what to competing social goods such as education, etc.? Or should this simply be left to
the operation of the free market and political jockeying?
✓ Can these even be a rational case for determining the total healthcare spending? Or local
budgets? Or is this best left to politics and tradition?
✓ What principle of morality prescribe and prescribe what we can do in the pursuit of more
efficient allocation of healthcare?
Unless and until the values of the particular society are clear and related to the
above, leaders will have difficulty justifying any resource allocation they
propose.

18. Mesoallocation deals with decisions
regarding many of the healthcare
resources should go to which kind of
services. Questions to answer are:

19. ✓ What kind of goals should the health system be addressing and in what
order? Are health promotion measures, for instance, to be included?
✓ Is the present distribution of resources between broad categories such
as health promotion and crisis-care fair and efficient?
✓ Should optometry, dentistry etc., be included?
✓ On what basis are choices between possible types of healthcare to be
made when not all can be afforded?
✓ What limits does the proper freedom of physicians, healthcare
institutions insurers and patients place on any scheme of just allocation
of healthcare?
✓ Is the provision of healthcare without the regard for efficiency morally
acceptable or even required?
Unless and until these are made clear, leaders will have difficulty justifying
their proposed distribution of resources among various health programs.

20. Microallocation deals with decision regarding
how a scarce resource should be distributed
among individuals with competing claims to
it. Questions to answer are:

21. ✓ Is the present distributor of healthcare resources between persons
“equitable” and “efficient”?
✓ What inequalities in healthcare distribution are morally acceptable?
✓ Who is to receive a particular treatment when it has to be rationed?
✓ Should factors such as religion, race, gender, age, ability to pay, regional
and social location be important? Should we, for instance, prefer the
young to the elderly?
✓ Should physicians try to do “everything possible” for their patients
irrespective of the needs of others?
✓ What principles of morality prescribe or prescribe what we can do in the
pursuit of more efficient micro-allocation of healthcare?
✓ In its starkest terms, “who is to be saved when not all can be?”
Unless and until these are made clear healthcare providers will have
difficulty deciding who they save.

22. TRIAGE is defined as the medical
screening of two patients to determine
their priority for treatment. It is a means
of microallocation. It considers two
principles: formal and substantive or
procedural.

23. Formal Principle. The formal principle states that scarce
resources should not be wasted but should be used
impartially giving equal weighs to the rights of all whose
lives are in jeopardy. It directs the triage decision maker to
apply evenhandedly whatever rules are deemed right
establishing.
Substantiative or procedural principles. The substantiative
principle proposes the right establishing criteria.

24. Thera are 2 groups of alternatives proposed:
A. The utilitarian alternatives. These represent
maximizing strategies to achieve the greatest
amount of good (the greatest good of the greatest
number) or minimizing strategies to reduce the
amount of potential harm.

25. 1) The medical success principle gives priority to those for whom
treatment has the highest probability of medical success. The
candidate with the greatest chance of getting well will be given the
scarce resource.
2) The principle of immediate usefulness gives priority to the
candidate who is of the greatest immediate service to the larger
group under the circumstances. In an epidemic, the heath
professional would be given priority. This principle is good for
emergencies but less easy to justify in non-emergency conditions
when “immediate” becomes a relative term.
3) The principle of conservation gives priority to those candidates who
require proportionally, smaller amount of resources and therefore
more lives would be saved. The candidate requiring less of a
resource would have priority over the candidate requiring more.

26. 4) The parental role principle gives priority to those
who have the largest responsibility to dependents. The
father with dependent children would be given priority
over a bachelor with no dependents. This principle is
difficult to apply in emergency conditions.
5) The principle of general social value gives priority to
those who believed to have the greatest general social
worth thus leading to the good of society. A leader in
the society would have priority over a non-leader.

27. B. The egalitarian alternatives. These represent maintaining or
restoring the equality of the person in need.
1) The principle of saving no one gives priority to no one because not all can
be saved. If there are not enough resources for all who need them then
no one should receive any. Since no one is selected it is a actually a
rejection of triage; saving no one will wrong all the candidates.
2) The principle of medical neediness gives priority to candidates with the
most pressing medical needs. The candidate with the most advanced
disease would receive the available resource. This principle gives
everyone an equal chance to be as healthy as everyone else but may be
inefficient for the neediest candidate may not be the one expected to
survive if treated. It is better considered as a supplement to other
principles

28. 3) The principle of general neediness gives priority to the most helpless
or generally neediest in an attempt to bring them as nearly as possible
to a level of well-being equal to that enjoyed by others. The poorest
candidate would receive the available resource.
4) The principle of first come first served or principle of queueing gives
priority to those who arrive first. The first one who asks, receives.
5) The candidate chosen in a lottery receives the resource. This principle
ensures equal opportunity and eliminates fallible human judgement but
is impractical and allows health professionals to escape from the
responsibility of triage.

29. The different principles can be combined. In an actual practice
ethicists generally agree that triage is a just procedure. A two-
step process is commonly suggested:
1) Listing acceptable candidates
Objective initial inclusion/exclusion criteria for choosing
the acceptable candidates are established. These may
include:
a. Constituency factors including clientele boundaries
b. Progress of science factors
c. Prospect of success factors (need and benefit factors)

30. 2) Selecting the specific candidate
Final selection criteria for choosing the specific
candidates from those in the preliminary pool are
made based on the substantiative principles of
distributive justice such as social value, immediate
usefulness, queuing, random selection.

31. A just society seeks to protect the dignity of its
members and to satisfy their basic needs.
 Society must decide what constitutes a minimum
level of satisfaction consistent with human dignity
and the resources available.

32.  In making this specification and setting this
minimum, the society is limited and influenced not
only by the needs of the members and the resources
available, but also by the need to keep itself
functioning.
Resources are always scarce, this direct distribution
involves a judgment evaluating various sorts of basic
needs and various ways of satisfying them directly.

33.  Adequate humane health care should include the
care necessary for the individual:
1. To avoid premature death
2. To function in society as a productive member
3. To be free of unnecessary physical pain in life
and death

34. 1. Needs –
a just system provides goods to its members on the basis of their
demonstrated need and their inability to satisfy it on their own.
ex. Denying food to a starving person is an attack on his or
her health and life and so on the dignity of that person
It has an intuitive attractiveness but does not consider scarcity of
resources
 Social Priorities- costs of basic goods, including health care, must be
considered when dealing with scarce resources.
Distributive Justice

35.  No society can provide everything that everyone
needs, let alone what everyone wants.
 Ethical distribution, must provide for PRIORITIES and a
system of ALLOCATING RESOURCES
2. Distribution thru Rationing –
not everyone can have everything she or he wants.
It means limiting consumption and parceling out the
goods that can be consumed.

36. In health care, basic needs such as the preservation of meaningful life
must take precedence over mere wants and desires and acquired
needs.
Ex. Saving the leg of an otherwise functional diabetic woman has
precedence over a treatment that might or might not prolong her life,
and might or might not improve the comfort of a functioning individual
who already has a fatal condition.
Distributive Justice

37. Allocation of Resources by the Patient
Patient makes decisions about the allocation of
his resources among all needs, including those
of the family