Tuesday, September 5, 2017

Health Care Ethics Textbook

1. What is Health Care?

2-6. What is Ethics?

7. Informed Consent in Health Care

8. Reproductive Ethics

9. Ethics of Dying

10. Allocation of Resources

12. Affordable Care Act

Sunday, September 3, 2017

Informed Consent in Health Care

In health care, the concept of "informed consent" has two primary applications: Informed Consent in Research and Informed Consent in Treatment.  In any Liberal Society these applications relate to the concept of "Human Agency," or the philosophical questions that underlie what kinds of persons can be held morally responsible for their actions.  There are two conditions: rationality and free will. In health care two questions dominate moral and legal debate. 1.) Was the research subject or patient given enough information to make a rational choice? and 2.) Once provided with this information, does the research subject or patient, have the ability to act "freely" on the basis of that information... in short, does that person possess free will.

There are many conditions that might impede a research subject/patient's ability to process information. First of all: much of the language associated with health care is highly technical and derived from Greek or Roman nomenclature, and therefore most of us do not understand what the researcher or physician is saying. And most researchers/physicians have not been trained in how explain medicine in laymen terms. Therefore, many research subjects/patients are vulnerable, and rely on third-party agents, usually nurses. The most vulnerable classes include: young children, persons suffering from mental diseases, persons with very low IQs, persons with little education, persons that do not speak English, and elderly patients suffering from varying degrees of dementia. In these cases, proxies, or other rational persons must make those rational decisions. But who... family or friends, physicians, lawyers, judges, or juries?  

There are also conditions that might impede a research subject or patient's ability to exercise free will, and consent to serve as a research subject or undergo costly, high-risk, medical treatments. Many potential research subjects/patients tend to defer these decisions to authorities who possess a Ph.D.  or an MD degree. Many research subjects/patients are vulnerable to outside interference because they are desperately seeking to avoid and/or remove pain and or disability. 

Informed consent has become an important moral/legal problem because researchers and physicians often have a stake in securing informed consent from prospective subjects/patients; and therefore may operate under a conflict of interest. Researchers need many research subjects in order to conduct clinical trials. Many researchers are college/university professors seeking tenure and promotion, researchers that are also pursuing lucrative patents for themselves or their respective corporation. Most physicians get paid for their services, and (like everyone else) needs to payoff student loans, feed, clothe, and shelter their families etc. Therefore, researchers and/or physicians might to tempted to misrepresent the known costs and benefits of serving as a  research subject or undergoing an expensive treatment. Sometimes these misrepresentations rise to the level of legal fraud. Sometimes these misrepresentations are paternalistic, and therefore serve the greater interests of the subject or patient, but sometimes these misrepresentations are predatory and serve, primarily the interests of the researcher or physician.  Research subjects may also be bribed into participation in a research project by offering either free health care or monetary reward. At what point does providing an incentive become bribery and/or economic predation (Kant)?    

Saturday, September 2, 2017

Reproductive Ethics

Introduction:

Questions concerning the moral and legal foundations of human reproduction are enormously complex. Some of the most important questions have become public issues that address the following: the moral/legal limits of reproductive assistance, the moral/legal limits on contraception, moral/legal limits on reproductive control by individuals, religious groups, and political regimes; and a cluster of issues that involve abortion. All five moral principles (utility, beneficence, non-maleficence, liberty, and justice) are often invoked in reproductive ethics.  

As an initial observation, let's all acknowledge that our individual and collective beliefs about human reproduction have been shaped by culture, religion, science, and politics. Today, all of these factors are also filtered through the media, especially social media.  

Reproductive Assistance and Control:

Since the 1970s, reproductive assistance has been shaped almost entirely by both "low tech" and "high tech" reproductive technologies. Low tech include simple procedure such as artificial insemination, that employ little more than a glorified turkey-baster; high tech, include in vitro fertilization, sperm injection, and cloning. 

Reproductive control includes who decides whether to have children, how many children, and on what basis might they decide, Hence "reproductive control" might include the use of contraception, the decision to continue a pregnancy, or abort a zygote, fetus, or infant, who decides and on what basis? 

Three Moral/Legal Perspectives

Reproductive ethics in the United States is most often reduced to two extreme views: the EXTREME LIBERAL POSITION (Liberty-Based): Anything goes, individuals decide whether to have kids, how to have kids, how many kids to have, and whether to terminate pregnancies at various stages of development. No laws are necessary. And the EXTREME CONSERVATIVE POSITION (Natural Law or Roman Catholic View).  

According to the Roman Catholic Church (via papal decrees), all sexual activity must take place within the "sanctity of marriage" between a male and a female via "natural" sexual intercourse." Three "sins" are to be avoided: sex outside of marriage (fornication) and sex outside of reproductive purpose via sexual intercourse (perversion), and abortion of a any fertilized ova, from zygote to birth. Thus, reproductive assistance within the church consists in making sexual intercourse more productive. Therefore, almost everything associated with In Vitro fertilization is regarded as immoral: donated ova and sperm, masturbation (to secure sperm), fertilization within a petri dish rather than within a uterus, and selective abortion in the case of multiple fertilized ova. Genetic testing, sex selection, gamete selection and storing frozen embryos are all regarded as an affront to "human dignity." In the case of blocked fallopian tubes, Roman Catholic fertility clinics may transfer those immobile embryos to the uterus. 

There are a variety of what we might call "MODERATE POSITIONS that fall midway between extreme liberalism and extreme conservatism. Most reflect intermediary views on the status of the fetus and/or utilitarian concerns with IVF. Many libertarians regard zygotes a "persons subject to moral concern," others identify personhood with various stages of fetal development, usually the developmental stages where fetuses can experience pain and pleasure. Others, argue that abortion of fetuses that will lead a short life of pain and suffering may be aborted at the earliest stages of development. Others, accept infanticide as well. Utilitarians might object to the cost of reproductive medicine in an "over-populated" world and/or the inability to regulate reproduction in a global context.   

Finally, it is important to distinguish between legality and morality. Libertarians tend to limit legal bans and mandates to major crimes such as murder, theft, and fraud. Many observe that fertility clinics commit fraud, when they "sell" IVF by overstating the likelihood that one or "cycles" of IVF will result in a "live birth," and that the cost of IVF is often obscured by charging patients per procedure, rather than per live birth. Many ultra conservative Roman Catholic scholars seek to legally ban IVF and abortion in all contexts, while others do not pursue legal bans and mandates for non-Catholics. Thus, many seek to distinguish between sins and crimes. 

Problematic Technologies    

In recent years several reproductive technologies have proven to be morally controversial: abortion drugs, genetic testing (for diseases, disabilities, and or sex), infant sex change operations, cloning, and the artificial uterus.



Sunday, July 16, 2017

Reading #20: Consumer Privacy

We've already discussed Employee Privacy. Much of that conceptual framework carries over to Consumer Privacy, especially the distinction between private and public information.

 First of all, the concept of "information" is epistemologically complex. The distinction between "public information" and "private information" is deeply rooted in Adam Smith's original distinction between "property" and "information." If there is a such thing as "private property," then why not "private information?" In what sense do individuals "own" information pertaining to their "private lives?" If there is a "right to privacy" is it a moral right or legal right? If there is a legal or moral right to privacy, then is that right a Positive Right or a Negative Right?  

So if corporations have a duty to respect the privacy of consumers, what kinds of information ought to be kept private, who is responsible for keeping it private, and how do they do it. Some kinds of information are widely recognized as "private:" financial information, health information, sexual preference, preferred Internet sites, online purchases etc. 

Stockholder Theory argues that, ultimately, it's consumers' responsibility to protect their own privacy, by limiting their communication to businesses that promise to protect that privacy. Health insurance companies need your personal health information in order to provide health insurance. Good health insurance companies would promise to protect that information via state-of-the-art information technology, or would consult patients before sharing with other third parties: employers, family members, the media, other sellers etc. 
No laws are necessary. Companies that promise to effectively protect confidentiality, will attract buyers that value confidentiality. Companies that do not promise to maintain confidentiality, may attract buyers who do not care about confidentiality. For example, I often visit guitar sites, both guitars and playing guitars. I don't care if those sites share my guitar interests with other sellers. However, I'd rather keep most of my health-related information private, therefore I rarely post anything online that relates to my personal health. No governmental involvement is necessary. Over time the free market will protect privacy, to the extent that some buyers demand it in various contexts. 

Stakeholder Theory argues that the free market often fails to protect consumer privacy, and that privacy can often be invaded without consumers even knowing that it is being invaded. Therefore, stakeholder theorists argue we need laws to protect consumers from the invasion of privacy, and the sharing (selling) of that private information to interested third-parties. For example, there are laws that protect the confidentiality of medical information. All providers are legally responsible for asking patients exactly who may have access to that information. The problem with these laws is that they make it difficult for friends and family to find out what's going on; and health care providers are forced to go through time-consuming, and resource-consuming bureaucratic lengths to provide the health care that patients want and need. Utilitarians might, therefore, argue that the costs of protecting consumer information far exceeds the benefits.             

Friday, July 14, 2017

Executive Compensation

The question of executive compensation is one of the more recent moral issues attract the attention of business ethicists. Here's the basic issue: "Are there moral constraints on how much corporate executives are paid?" The salient moral principles are utility, liberty, and justice.

Utilitarians argue that executive pay ought to be subject to the "greatest happiness principle:" or "the greatest happiness to the greatest number." Thus, there are consequences for both over-paying and under-paying executives. If the CEO is a utilitarian, then he would be inclined to

Stockholder Theory says that the CEOs primary moral/legal obligations are toward the owners of the company, the stockholders. Compensation of any given "executive" would be based on how much he contributes to the value of the company's stock. If that executive is (in fact) largely responsible for increased stock value, other companies might seek to hire that executive, and offer more salary, thus contributing to a bidding war. Thus, it's up to stockholders to determine "how to pay executives" and how much to pay executives." It is widely accepted among stockholder theorists that the interests of the stockholders and the executive must be aligned. So if any given executive (or CEO) earn more for the stockholders, the ought to pay him more. If not, they ought to pay him less. In the end, if valuable executives are under-paid, then they'll exercise the Liberty Principle and move to another company, when their contract has expired. If stockholders over-pay executives, there will be less money available to pay other employees, less money for advertising, less money for research and development etc. In the end, the Liberty Principle rules supreme, no governmental bans or mandates are necessary. The free market determines fairness.   

Stakeholder Theory says that there is a social cost for overly-generous executive compensation. The more you pay executives, the less money you have left to pay other employees, financiers, and suppliers. Therefore, the CEO must take into account there other stakeholders. Some stakeholder theorists even defend the concept of a maximum wage, an objective limit on how executives are paid, and how much they are paid. Sometimes maximum wage might be set as a percentage of how much the lowest-paid workers are paid; maybe no more than 500% (5X)  of the minimum wage. Others might argue, that all "raises" must be across the board, and that if an executive gets a 10% raise, so should everyone else. Of course, most stakeholder theorists would argue that there must be laws governing both minimum and maximum wages.

 Today, executive compensation is often determined on the basis of cronyism; that is, the executives and the chairmen of the boards (stockholders) choose to reward one another, regardless of merit. Then, they disguise their mutual rewards behind a smokescreen legalese and/or verbal contracts behind closed doors. Stockholders, therefore, must insist on transparency, in order to minimize cronyism. The media often plays a role in exposing overly-generous compensation for both executives and board members.             

Wednesday, July 12, 2017

Reading #23: Bribery and Corruption

Another problem associated with the global market is the widespread use of bribery and kickbacks in other countries. In most Western countries, offering a bribe and paying a bribe are considered immoral, but the legal systems tend to treat the offerers different from the payers. In many parts of the world, bribery is regarded to be a necessary evil, a business expense, and the cost of doing business. Many cultures regard gift-giving as a necessary part of establishing working relationships. So, one of the initial puzzles is how to differentiate between a “gift” and a “bribe.”

In many countries bribery is regarded as tradition. Public officials in many countries are routinely under-paid relative to market forces, and therefore they supplement their income by taking bribes. Of course, there are small time petty “bribes” by lower level public officials, and big time “BRIBES,” by higher level officials. Is bribery always wrong, never wrong, or sometimes wrong? Are there hyper-norms involved?

The most serious problem with regulating bribery at a global level is that it is that it is almost impossible to monitor and enforce laws against it. It takes place in private. Bribes are often perceived by both offerers and payers as a business opportunity, and therefore tend to perpetuate the tradition.

Conceptually, bribery is a problem for both stockholder and stakeholder theorists. Stockholder theorists tend to embrace “When in Rome do as the Romans do." But on the other hand, bribery obviously raise the cost of doing business, without adding to the value of the product or service. Stakeholder theorists promote international laws that insist on corporate “transparency” and laws that make it more difficult to pay bribes, especially laws against money laundering. Stockholder theorists often argue that some of these laws violate the right to privacy, or that these laws are costly and ineffective.

Tuesday, July 11, 2017

Reading #18: Consumer Health and Safety

We already discussed Employee Safety in the workplace. What do business ethicists have to say about Consumer Health and Safety? Again, the two basic philosophical issues are: How healthy is a healthy product or service? And, how safe is a safe product or service. In short, what are the moral/legal standards?

First, let's admit that there are no products and services that are 100% healthy and/or safe. That's because, both health and safety are subject to both short-term and long-term utility. Eat a steak for dinner tonight, will certainly be a highly pleasurable experience; especially if it's accompanied by a couple of glasses of wine. There are also health benefits associated with eating red meat. Problems arise when consumers eat steak at every meal over a period of many years. Obviously, there is a financial cost associated with eating steak every day. But there are also health risks associated with eating large quantities of red meat over a  long period including: cancer risks and heart disease risks. As for safety, eating steak carries with it a risk of choking, therefore, it is advisable that you chew your steak thoroughly before you swallow it.

There are also short-term and long-term benefits and risks associated with drinking wine. Over the short run, wine will aid in the pleasure digestion of food, but it can also be financially risky. If you drink more than 2-3 drinks, you are liable to get intoxicated, or at least intoxicated enough to crash your car and/or get a ticket for DUI. If you are pregnant, drinking alcohol poses a risk to developing fetuses. Over the long run you can also become an alcoholic, end up in prison, and ruin your family life.

So the basic issue remains: what are the moral/legal duties that accompany selling various products and services? Traditionally, most sellers willingly "warn" buyers of the most serious harms. Most alcoholic beverages are legally required to post a warning label that informs pregnant women that alcohol consumption might harm their fetus. Tobacco products are legally required have a warning label stating the risks of cancer and heart disease. Again, for business ethics, the main issue here is whether the government ought to force sellers to disclose all known harms or whether the free market will adequately inspire sellers to expose risks to buyers.

Stockholder Theorists argue that it's probably in the interest of sellers to share information about the health and safety of products and services. If they don't other third parties will do it, especially consumer groups and the media. However, labels are designed, primarily to attract buyers, therefore labels that are excessively complex, loaded down with minimum risks, are counter-productive: buyers are less likely to read a long diatribe. Once, buyers are warned of risks, the Liberty Principle guarantees that consumers have a right to take risks; and that State Paternalism violates the Liberty Principle.

Stakeholder Theorists are Kantians, and therefore argue all products and services ought to be as healthy and safe as possible, and that government ought to set those standards, monitor and enforce those standards. Some unhealthy and unsafe products and services are deemed illegal for everyone, others are illegal only for certain groups. When health or safety standards are violated, government punish sellers with fines and/or other legal sanctions. Stakeholder theorists tend to expand State Paternalism, by regulating what can be sold to whom. State paternalism is especially evident in laws that forbid and/or regulate: prostitution, gambling, and selling pot. Most Stockholder theorists argue that the more states regulate buying and selling, the fewer the buying opportunities, and the less happy we all are. In short, there is an inevitable tradeoff between legally imposed health and safety standards, the cost of products and services, and the happiness of consumers. I'll have another serving of steak and another glass of cheap wine. But I'll pass on the heroin and the prostitute. I don't need any advice or protection from government.