Justice and the conflict among principles
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Justice and the Conflict Among Principles. Robert M. Veatch The Kennedy Institute of Ethics. The Shortage of Kidneys for Transplant. OPTN database, 2012. Waiting List. OPTN/SRTR database, 2004. Opening Case: Kidney Allocation. 1980s:HLA tissue-typing (efficiency)

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Justice and the Conflict Among Principles

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Justice and the Conflict Among Principles

Robert M. Veatch

The Kennedy Institute of Ethics

The Shortage of Kidneys for Transplant

OPTN database, 2012

Waiting List

OPTN/SRTR database, 2004

Opening Case: Kidney Allocation

  • 1980s:HLA tissue-typing (efficiency)

  • 1990s:Time on the waiting list (fairness)

  • 2011:The “20/80” Proposal (efficiency)

  • 2012:The absence of fairness

Individual vs. Social Ethics

The Hippocratic Ethic:

  • Benefit the patient and protect the patient from harm

  • Beneficence and nonmaleficence

    Autonomy or respect for persons

  • Nonconsequentialist

  • Duty-based

  • Deontological

Ethical Principles for Morality Between Individuals

Ethical Principles for Social Morality

Ethical Principles at the Social Level

  • Social Utility

    • Maximizing the aggregate net good from available resources

      • General units of social utility (utiles)

      • General units of health utility (QALYs)

        (Quality-adjusted life years)

Two Utilitarian Worlds

Ethical Principles at the Social Level

  • Justice

    • Creating an end-state pattern of distribution of the good

Meanings of the Term “Justice”

  • Aristotle distinguishes:

    • Broad sense

    • Narrow sense

  • Aristotle’s three end-state patterns

    • Free birth

    • Noble birth

    • Excellence

Modern Egalitarian End-State Patterns

  • Equality of well-being

  • Issues in measuring equality of well-being

    • Subjective vs. objective theories of the good

      • Preferences

      • Satisfaction of desires

      • Objective theories

    • Equality of well-being and equality of opportunity for well-being

    • Dworkin: Equality of resources

John Rawls “Relatively Egalitarian” View

  • Theory of Justice, 1971

  • Two principles of justice:

    • Equal right to basic liberties

    • Social and economic inequalities are to be arranged so that they provide the greatest benefit to the least advantaged and are consistent with fair equality of opportunity [“the maximin”]

Egalitarian Alternnatives to the Maximin

  • Prioritarianism

    • Gives priority to the poorly off

    • Not necessarily absolute priority

  • True or “radical” egalitarianism

Three Objections to Egalitarianism

  • Leveling down

  • Bottomless pit

  • Extravagant tastes

Two Final Problems

1. Reconciling the Conflict Among Competing Principles

a. Single-principle theories

b. Multiple principle theories

  • Balancing theories

  • Ranking (lexically ordering)

    • Primum non nocere

    • Rawls ‘s two principles

    • Judaism

  • Combining balancing and ranking

Combining Ranking and Balancing

Two Final Problems

2. The Clinician’s Role in Dealing with the Principle of Justice

(Two Options)

  • Let clinicians abandon their patients at the margin


    • Difficulty in calculating

    • Requires abandoning patient-centered ethic

Two Final Problems

b. Give clinicians an exemption from the principles of social ethics

  • Permits them to remain loyal to their patients

  • Requires that other parties do the rationing

Thank You

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