Jason T. Eberl, Ph.D. Semler Endowed Chair for Medical Ethics College of Osteopathic Medicine Marian University

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1 Jason T. Eberl, Ph.D. Semler Endowed Chair for Medical Ethics College of Osteopathic Medicine Marian University Affiliate Faculty Indiana University Center for Bioethics Fairbanks Center for Medical Ethics, IU Health

2 Basic Ethical Theories Foundational Principles of Biomedical Ethics Fundamental Ethical Tension in Public Health Principles of Public Health Ethics Toward a More Virtuous Citizenry Discussion: Ethical Dilemmas

3 Utilitarianism Deontology Virtue Theory

4 Consequentialist principle Only the consequences of an action count in its moral evaluation Principle of Utility Greatest good for the greatest number or The needs of the many outweigh the needs of the few or the one. Principle of Impartiality Everyone counts as one and no more than one

5 Immanuel Kant Principle of Respect for Persons Always treat persons, whether in your own person or in that of another, as an end in themselves and never merely as a means to some other end W.D. Ross Duties of fidelity, reparation, gratitude, justice, beneficence, self-improvement, and nonmaleficence Beauchamp and Childress: Beneficence, nonmaleficence, justice, and respect for autonomy

6 Focuses on moral character as opposed to the morality of human actions Virtues are habits (or dispositions) that are cultivated to benefit human flourishing Excellence in one s proper function The proper function of human beings is defined in terms of being a living, sentient, social, and rational animal.

7 Respect for Autonomy Beneficence Nonmaleficence Justice Beauchamp, TL and Childress, JF Principles of Biomedical Ethics, 7 th ed. New York: Oxford University Press.

8 Defined in terms of liberty and agency Is had by a person in degrees Not purely individualistic Entails both negative and positive obligations

9 Obligations expressed in the Hippocratic Oath I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them Generally, obligations of nonmaleficence override obligations of beneficence in cases of conflict

10 Utilitarianism Rights based on justice are strictly contingent upon social arrangements that maximize net social utility Libertarianism Society is to protect rights of property and liberty Focuses not on increasing public utility or meeting the needs of citizens, but on the unfettered operation of fair procedures

11 Communitarianism Principles of justice are pluralistic, deriving from various conceptions of the good What is due to individuals and groups depends on community-derived standards Justice as solidarity Egalitarianism Individuals are basically treated equally, but a preferential option may exist for the least advantaged Each member of society should have equal access to an adequate, though not necessarily maximal, level of social goods

12 Utilitarian principle: The needs of the many outweigh the needs of the few or the one. Libertarian principle: Over himself, over his own body and mind, the individual is sovereign.

13 Harm Principle Principle of Least Restrictive Means Reciprocity Principle Transparency Principle Upshur, REG Principles for the Justification of Public Health Intervention. Canadian Journal of Public Health 93(2):

14 John Stuart Mill: The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant.

15 Upward sliding scale from less coercive means, to more coercive means, to the full force of state authority and power. Education, facilitation, and discussion should precede interdiction, regulation, or incarceration.

16 Society is obligated to facilitate individuals and communities to discharge their ethical duties. Compensation for sacrifice of income or time.

17 All legitimate stakeholders should be involved in the decisionmaking process and have equal input into deliberations. The manner in which decisions are made should be as clear and accountable as possible. The decision-making process should be as free as possible from political interference or domination by specific interests.

18 The Latin word virtus refers to power or capacity. A virtue is a disposition to act in ways that will contribute to individual and communal flourishing. The term also refers to having the ability to act in such a way.

19 A truly virtuous citizen will be disposed to exercise their individual responsibility to better, or at least not worsen, their own condition (e.g., health), while also contributing to the common good. However, cultivating this disposition or having the ability to actualize it requires input and support from one s community (family, friends, government, etc.)

20 While it is up to an individual person to fulfill their responsibility to exercise regularly for the sake of their own health and fitness, it is incumbent on society (whether through the market & private philanthropy or the state) to provide access (in terms of location and affordability) to fitness centers, such as the Chase Legacy Center on the near-east side. This accords with the reciprocity principle of public health ethics.

21 Private health insurers or the state provide incentives for individuals to develop the habit of monitoring their own health or to contribute to public health benefit in some way. The Indiana Blood Center offers donation incentives (Carb Day and Kings Island tickets) and also provides donors with basic health information about themselves (blood pressure, cholesterol). Some private insurers offer discounts on premiums for meeting certain health benchmarks (cholesterol levels, BMI, etc.)

22 The state restricts tobacco smoking in public places. This does not impinge upon one s individual freedom to smoke in their private residence, but follows the harm principle in minimizing the impact of smoking on the health of others. Could cigarette smoking in one s car or home be construed as contributing to a hazardous environment for one s child?

23 Issues of justice: Should alcoholics be denied access to liver transplants, even if they are in recovery? Should products that are known to have a negative impact on health be taxed more heavily and such funds utilized to support publicly-funded hospitals and Medicare/Medicaid programs?

24 Issues of autonomy: Should tobacco be prohibited altogether? Should alcohol purchases be limited?

25 Issues of beneficence/nonmaleficence: Should processed foods, sodas, etc., be regulated in order to prevent individuals from harming themselves through poor dietary choices? Should the government subsidize organic or otherwise more healthy food options to make them more affordable?

26 Public Health Ethics: Theory, Policy, and Practice, ed. R. Bayer, L. O. Gostin, B. Jennings, and B. Steinbock (New York: Oxford University Press, 2007). Public Health Ethics, by Stephen Holland (Malden, MA: Polity Press, 2007).