Public Health Ii Notes

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:

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.

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.

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 policy-level of decisions

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.

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.

Non-aggregation - the cost-effectiveness 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...

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