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Public Health II: Ethics of Prevention Public vs. Private Health Ethics A. What makes public health ethics different from clinical ethics? The goods being protected, the decision makers, the role of autonomy, the temporal focal point...?
B. To illustrate the difficulties that arise from these differences, we will focus on two hard questions of health law policy that arise around the ethics of prevention.
Arguments re Treatment vs. Prevention Brock & Wikler The main contention by Brock & Wikler is that, since all human lives are equal, given limited resources, and all other things held equal, there can be no sound moral basis for giving any priority to the saving of identified lives over statistical lives, especially since multiple studies have shown that prevention saves more lives (B&W View). In particular, the vision of ensuring global access to AIDS treatment rests on some assumptions like the availability of funding to keep up with the rate of AIDS being diagnosed, that universal access to AIDS treatment is actually achievable, and that funding is sustained indefinitely. The main opponents of the B&W View contend that all other things are not equal, and thus disagree with the fundamental premise (i.e. that all human lives are equal). In particular, the inequality is in the identified and statistical individuals' respective entitlements to be saved. The seven main arguments advanced in support of varying entitlements are as follows, and all aim to show that failing to offer treatment is morally inexcusable:
1. Equal worth because every life is equal, we must offer the same level of care to every person in need
B&W don't think this argument goes anywhere re the treatment/prevention debate
To the extent that it has any relevance, it would be in support of a consequentialist approach to public health ethics i.e. the more we save, the better, and since all lives are equal, the prevention approach would be preferred.
2. Rule of rescue the fact that we can save identified lives of people who are immediately threatened creates an obligation to do so that must be honoured (i.e. justifying treatment over prevention), even if doing so reduces the number of lives saved overall
B&W respond with the miners example no resources will be spared to rescue trapped miners even if safety measures that would have prevented the cave in were deemed too expensive when proposed the previous year.
B&W claim that this rule is best understood as a fact of human psychology, and not as a guiding normative principle. They do acknowledge that if the argument is spun a different way (i.e. that people will be more willing to fund a treatment program than prevention campaign, then the choice is between a well funded treatment program or a poorly funded prevention campaign), there is plausibility. However, they think this redirects the question of treatment vs prevention, and offers an alternative solution.
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3. Identified vs statistical lives; present vs future lives the rule of rescue emphasises the saving of identified and present lives (hence justifying treatment over prevention). This is connected to the ex ante vs. ex post issue if what is important is expected well being (i.e. the ex ante approach), then treatment must be favoured over prevention (the final utilities, or ex post approach).
B&W claim that the principle of equal worth of lives conflicts with and undermines the moral significance of both of those distinctions (since a life saved now, whether statistical or real, is just as valuable as a life saved in the future, whether statistical or real), and that in any case, neither distinction directly mirrors the treatment vs prevention debate sometimes lives saved in a prevention program are identified, and sometimes lives can be saved just as quickly by prevention as by treatment
B&W also acknowledge that discounting of future lives might appear to justify the saving of present lives, but that this logic is not uncontroversial, especially in light of the 'all lives are equal' principle.
B&W do acknowledge that the saving of identified lives makes more sense in certain cases e.g. where we have special relationships with the person; but that this does not, or only makes limited sense in the policylevel of decisions
4. Uncertainty closely connected with the above, the inherent uncertainty of the future and how many lives would be saved by a prevention program (as opposed to a treatment program) seems to go against the former.
B&W argue that to an extent, there is double counting here the uncertainty of the future should be factored into the original estimate of how many lives would be potentially saved by the prevention program. To again discount those lives by virtue of them being in the future would be to double count.
5. Priority to the worse off benefiting people matters more, morally, the worse off they are, which justifies treatment over prevention. Inherent in this is an ex ante vs ex post issue: if the former view is adopted, then an argument in favour of treatment is stronger because we know ex ante who needs to get treated, and those that need treatment have a stronger claim to treatment than those who are only at risk (contractualist reasoning).
B&W argue that without prevention, people will become those that need treatment, and that the only difference is when those people become people who need immediate treatment. Further, if the latter ex post view is adopted, then prevention is clearly the better option.
6. Nonaggregation the costeffectiveness analysis as a means of health resource allocation should not be done on an aggregate basis i.e. the sum of a great number of small inexpensive benefits should not be allowed to outweigh the impact of a benefit conferred that may be more expensive but have higher impact. This means the claim of a HIV patient who requires immediate treatment should not be defeated by the fact that the resources allocated to that one patient could also be allocated to a bunch of others for the purposes of prevention, which might be more costeffective in the aggregate sense.
B&W argue that, similar to the 'priority to the worse off' perspective, the difference between treatment now vs. prevention now is only a matter of timing. It is correct that the claim of
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the HIV patient who requires immediate treatment is strong, but for those who may contract HIV in future, and eventually become like the current HIV patient, their claims are also strong.
This also ties in with the prevention paradox in the sense that preventative measures tend to have the greatest efficacy when targeted at those with medium to low risk in the population, as opposed to being targeted at those with high risk.
7. Urgency when medical resources are scarce, it is common to treat the most urgent patients first
B&W argue that this is only true when scarcity is temporary. When it is over the long term, giving priority to urgent cases is tantamount to determining who lives or dies, and there is no compelling moral reason for them to give priority to the patient whose needs are most urgent at any one point in time. B&W concede that certain claims could be raised to support treatment over prevention (e.g. if we have to stand by and not save identified imperilled individuals because our efforts and resources could be used instead for prevention efforts that would save more statistical lives, this could be dehumanising and eroding of important moral motivation and compassion for others, with bad effects on balance for preserving human life), but these would need to be supported by the empirical evidence on which they depend. Johann Frick The main contention by Frick is exactly that which B&W raised i.e. a fundamental disagreement about the fact that 'all other things are equal'. Frick raises the argument that people who are in need of treatment have a morally superior claim to those that would benefit from prevention, and does so on the basis of two preliminary steps: 1
Rejection of actconsequentialist aggregation of benefits/burdens upon which B&W's claim is grounded
Frick argues the aggregative nature of consequentialism denies proper concern for the individual (failing to respect the separateness of persons), and leads to counterintuitive conclusions e.g. if we can save one person from terminal cancer, or one million people from chronic headaches, the consequentialist would consider the latter option as morally superior.
Frick's solution to this is the model of 'competing claims' (i.e. contractualism) wheres morality requires us to determine that action or policy which satisfies the strongest individual claim or minimise the strongest individual complaint raised by any individual.
The contractualism approach accepts that it is better to save a greater number of lives as opposed to a smaller number of lives where what is at stake for either group is certain death. But in the case of identified lives vs statistical lives (treatment vs prevention), the comparison is not equal.
This contractualism approach can be used to respond to the mining example given above by B&W. The mining issue, unlike the AIDS issue, can always be decided upon ex ante for certain parties, and so it would make sense, between two methods of
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