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Rhoden, "Cesareans and Samaritans": She defends that courts should not order competent women to have C-sections, despite the potential tragic consequences to the fetus. Civil libertarian position: 1. Impose an unparalleled intrusion upon pregnant women 2. Undermine the teachings of informed consent 3. Goes against women's choices during obstetrical care.

She outlines reasons why C-sections are justified and then argues against them:

ABORTION LAW- But the fact that states have an interest in preventing certain consequences does not mean that any and all action to prevent such consequences is constitutional. Roe v. Wade allows the state to protect the fetus but she argues this not applicable. The woman's health should come first and her rights should not be compromised.

THE CHILD NEGLECT/ FETAL NEGLECT ANALOGY- seen as a harmful choice the woman is making toward the baby. Analogy is too simplistic- there are no legally enforceable duties to fetuses.

THE STATE"S INTEREST IN THE WELL-BEING OF THIRD PARTIES- there is no general duty to rescue and certainly no duty to undertake risky rescues. "good Samaritans" NOT "splendid Samaritans"

Rhoden makes analogy to bone marrow transplants and C-sections. The court orders someone to undergo surgery to save another. Pregnant women have the right to be cowards and afraid of a surgery especially under emergency situations. Religious beliefs of the woman should be taken into account as well. Subjective ordering of the court where they cannot possibly understand. 2 scenarios: Violence involved if a woman objects to the surgery and if the woman dies who is morally to blame (the court?)
Stating that "disobeying medical advice" is a crime is silly and dangerous. Silly because advice is advice, not the law. Dangerous because the term "advice" is vague and could mean just about anything
Focuses on the fact that the court cannot charge a pregnant woman with child neglect or "fetus neglect"
How can you favor the fetus over the mother? To do so would reduce mothers to individuals capable of serving only one function: childbearing. They would be nothing more than containers
Also a woman has her own autonomy and to force her to not do certain things would be violating her autonomy
If the court rules for fetus neglect then they are placing greater priority in the unborn fetus then in the pregnant women instead of acknowledging that doing something to one with effect the other since they are inseparable until born
Attempts to define fetal neglect, and to establish a prenatal police force to protect fetuses from their mothers, are steps backwards in terms of both women's rights and fetal protection. Women's rights will only be protected when we treat women equally.
Annas
"Pregnant Women as Fetal Containers"- when is it legally acceptable to treat a pregnant woman as a container, while treating the welfare of the fetus she contains as more significant than hers. Monson in CA 1986 charged for not listening to her doctor and getting to the hospital soon enough. She sees defining fetal neglect laws as steps backward in terms of both women's rights and fetal protection. Women's rights will be fostered when we treat women equally. For fetuses we need to protect by enhancing the status of women by fostering reasonable pay for the work they do, equal employment opportunities, and providing a reasonable social safety net, quality prenatal care, and day care services. The state should protect the welfare of the pregnant woman- not by oppressing them.
o Somatic-cell interventions -treat any cells of the individual, except the gametes, at the cellular level to correct an absent or malfunctioning gene
Attempt to remedy the causes rather than alleviate effects of the disease provide more effective and beneficial medical treatments
o Germ-line intervention attempts to repair or replace malfunctioning genes, treats the gametes or an embryo, which would be used in the case of in vitro fertilization
o principal difference is that the corrected gene, rather than the deleterious one, is passed-on to subsequent generationsthe potential benefits or effects of germ line therapies could be much more widespread than those of somatic therapies
o Somatic-cell interventions fix at the molecular level rather than focusing on the organs and other things; therefore, it is seen as a more sophisticated method. So long as they are safe, the interventions are okay. However, a patient tied under experimental treatments thus prompting public outcry
o Against germ-line
humans should not attempt to construct the genetic inheritance of future generations
Individuals carrying a recessive deleterious gene, for example, might in the future incur certain survival advantages in response to changing environmental factors much more widespread consequences than those of somatic interventions
Humans do not have a right to shape the genetic endowment of their descendants
"enhanced children" or "designer babies"
Slippery slope & playing God


o Therapeutic interventions - performed for the purpose of medical treatment such as chromosomal defects
o Enhancement interventions - designed for the purpose of enhancing performance in one way or another; efforts to make someone, not just well, but better than well
regarded categorically as violations of international human rights principles or other religious or moral values
o Concerns:
What is normal
When is it truly therapeutic or enhancement
undermining of the principle of social equality and the problem of creating an unfair advantage that would be enjoyed by enhanced individuals
playing God
concerns center on augmentation of functions that without intervention would be considered entirely normal
o Joint account model - genetic information is shared by more than one person.
o In a personal account, which concerns patient confidentiality and its limits, physicians face the problem of breaching the confidentiality of the patient if a third party asks for the patient's genetic information.
o However, in a joint account, it is assumed that information should be available to all account holders (meaning all family members) unless there are good reasons to do so otherwise.
o A family history will be constructed, which would draw familial information about diseases that members of the family have had. This history will make it easier for physicians to treat patients.
o A joint account model will benefit family members who are unaware of their family history.
o Joint accounts are consistent with clinical genetics. This is because geneticists work with families, and often develop a sense of responsibility for members of a family. A joint account of genetic data would make it easier for physicians to treat patients.
o A joint account would extend the benefits of testing when there is no risk of serious harm to index patients or their relatives.

o Joint account model: the genetic information is shared like a joint bank account—anyone with a relatively close relation to the person of interest has access to their genetic information
o Advantages
expose relevant information to others it may be applicable to, allowing them to be made aware of, and become knowledgeable about their own genetic risks and make appropriate decisions about reproduction
Justice: strongest support for it - familial genetic information applies to all relatives so what is available to one person (the source of the information) should be available to all
allows physicians to better diagnose and advise the patient as to their conditions and risks
the benefits to be gained outweigh the harms of violating confidentiality
its consistent with clinical genetic practice - geneticists work with families = they're responsible for everyone in the family not just the one that they are strictly consulting
o Pre-implantation genetic diagnosis (PGD) concerns selecting and screening certain embryonic cells for abnormalities. When embryos reach the 8 cell stage, specialists remove a single cell to analyze for chromosomal abnormalities. Clients can then select embryos free of certain diagnosable genetic conditions and diseases.
o Robertson's assessment of PGD
The issue at hand is the morality of creating and destroying embryos on genetic grounds versus the general idea of selecting embryos and thus putting greater value on some traits over others.
Robertson is concerned that increasing the scope of genetic screening of prospective children will move us toward a eugenic world in which children are valued more for their genotype than for their inherent characteristics.
Those who are against abortion tend to see PGD is embryo killing.
Those who are in favor of In-vitro fertilization (IVF) tend to see PGD as a method to increase the chances of embryo viability.
Some people find PGD acceptable as long as it is used on medical grounds, such as PGD for matching an existing child or for children with fatal acute diseases.
Robertson is also concerned about using PGD for gender selection
• However, PGD for gender variety is a stronger case because the risk of sexism is lessened.
He is also concerned about using PGD for other nonmedical related issues such as deafness, sexual orientation, or other traits.
If PGD is available to prevent offspring with serious genetic diseases, then PGD for late onset disorders and susceptibility to cancer should be acceptable as well.

o early onset/fatal diseases
it is ok to use PGD for selection due to the suffering that would be brought on both the child and the family
o late onset diseases (fatal)
fact that a disease is late onset shouldn't matter, it will still be a major source of suffering
the same rational as early onset diseases is applicable to this situation
o quality of life conditions
it is ok to use PGD due to the suffering
quality of life is a serious consideration and the burdens on the child and family are legitimate reasons for the use of PGD
o HLA matching for other children
having child for this reason is not likely to decrease the parent's love for the resulting child
it's not intruding on the child if just taking cord blood, if doing something invasive like bone marrow then its more questionable
not commodifying resulting child
o Gender selection (for nonmedical reasons)
selecting for first child
• mostly a potential problem in countries where strong gender preferences (usually for males)
selecting for subsequent children
• this is ok because it is more likely to be due to a desire for gender variety, having the sex that did not have the first time, not because they believe one is better than the other
• it's a legitimate desire to want to raise children of both genders
o Non-medical traits
ex. hair color, intelligence
in order to allow for the other options this will have to be allowed as well; it is a parent's right to exercise control over all parts of the offspring's genome
The main argument that is against genetic testing is connected to the idea of the slippery slope argument. If we would be able to test everyone for diseases and gender it might promote sex selection, and abortions of fetuses that have certain diseases because the parents do not believe they are 'perfect' (The need to prevent various forms of genetic discrimination). Another argument against genetic testing could be said to be the idea of genetic information being private, and that not everyone needs to know - even maybe the individual him/herself. Some people would rather not know if they have a terminal genetic disorder, something that mandatory testing would breach. One more could be the lack of access to everyone, these procedures are expensive, and everyone not having the same opportunity to test if they have a genetic defect is against the principle of justice.

The main argument for genetic testing could be said to be the idea of being able to screen diseases ahead of time. Some diseases such as Down syndrome are manageable and the death rates from such diseases are not as high compared to other genetic diseases. Allowing the parents to find out if their future child is going to have a terminal illness or have challenges in their lives will allow the parents to become more aware of what they can do. Testing will allow physicians to work on further testing solutions and therapies in order to cure some genetic defects, and catching these defects earlier is much more advantageous for the patient since some treatments might not work that effectively if diagnosed in further stages of the disease.
Dorff's analysis of stem cell research comes from both theology and law. Our bodies are not our own, but are gifts from God, who places certain obligations on them, including the stipulation that me must work to preserve ourselves. Natural and manmade treatments are OK because the Jewish tradition calls on us to work to heal ourselves. All humans are created in God's image and should be respected as such. We do not have God's omnipotence so we need to be cautious in our efforts not to do more harm than good in our actions.
According to the Jewish tradition, abortion is only acceptable if it was done for legitimate reasons. The woman can't abort just because she does not want the baby because that wold be like amputating her thigh for no reason. The fetus is not a full person, so if the fetus puts the health of the mother in danger, or will suffer from a terminable disease, abortion is acceptable, and may even be mandatory. If the fetus was aborted legitimately, it is OK to use the fetus in research to help others (does not have to be buried for god because it's not a person). As long as gamete cells are not in the womb, they will never be full fledged persons so they can be used for legitimate research.
The technology for stem cell research is morally neutral and requires a cost benefit analysis. Health care is a communal responsibility and the government has the right to demand that the companies they fund work to help those who cannot afford health care. Also, research for healing is good, but research for enhancement should be approached with caution. Dorff recommends funding stem cell research for its good purposes, ensuring access by al Americans, and limiting its uses for enhancement.
Shari'a (Islamic law) treats cells from aborted fetuses as similar to cadaver donation and therefore it is acceptable to use them to save lives. No real answer as to status of embryo, but it is safe to assume that the majority of Muslims would approve of a therapy from stem cells if it helped save lives. The Islamic ruling (fatwa) has changed overtime based on the current science and beliefs of the time. The Koran says that a fetus becomes a person at the later stages of pregnancy and distinguishes between a moral and biological person. Early Shari'a law says that a fetus is a person when it moves in the womb, and when it develops a stomach, around the fourth month. Islamic tradition allows for justifiable abortion until the end of the fourth month. Some believe that life begins at conception and should be protected. Once the fetus is alive, aggression towards it is like aggression towards a full fledged person. Different Islamic countris follow different customs. But all Muslims would likely agree that: the Koran and tradition say that potential life begins at the later stages of pregnancy, the fetus only gets moral status when it makes voluntary motion, the absence of any clear definition allows for people to come up with their own definitions for biological and moral persons. God's will is suprme and huans can only use stem cell research if it is done to improve life.

While all of these beliefs argue that life should be respected, they differ in their extent that the fetus should be protected. The Catholic and Protestant perspective is that life begins at conception and the fetuses should be respected, while the Jewish, new Catholic, and Islamic perspectives grant more leeway in terms of research. The Islamic perspectives gives people more say in their beliefs. All of these perspectives acknowledge that research for healing, not enhancement is important.
Whether or not to use federal funds for research
Reasons against research
• States that stem cells can be derived from sources other than embryos
• There are moral concerns raised by human embryo stem cell research. Even the most noble ends don't justify the means
• Human life is a sacred gift from our Creator. Supporting it may create a culture that devalues life instead of respecting it.
• Fetal tissue research also offered great hope for cures and treatment, but it has not met its expectations. Embryonic stem cell research has promise but at a great cost. He isn't sure he wants to take the risk, especially if it doesn't live up to the speculated potential.
Decision
• Allow federal funding to be used for research on existing stem cell lines.
Justification
• The decision to kill the embryo has already been made, so it is not immoral to use them.
• It allows for the research to progress, but not at the expense of potential life.
• Funds could go to the creation of stem cell lines or research on those lines. If they gave funds for the research but not the creation... that would still encourage the creation of lines through private funding. By adding the clause that no federal funding will be given to research using new lines... researchers aren't encouraged to create new lines. Bush does not want to indirectly support the creation of new (more) lines by supporting the research using them.
• They are giving funding to alternatives that don't involve the same moral dilemma
o Researchers endangered the lives of their subjects without informing them of the risks or obtaining their permission
o Unethical and questionably ethical procedures were common
o Pressures of advancement and promotion motivated these researchers to do these risky procedures
o Research ethics was not a widespread concern
o The turning point in human experimentation in the US was WWII, practices established during these yrs. influenced researchers' behavior in the postwar
o At this time clinical investigations became well-coordinated, extensive, centrally funded team efforts, & experiments were designed to benefit not the subjects but others (like soldiers who were vulnerable to the disease)
o Pres. Roosevelt created the Office of Research and Development to oversee the work of the Committee on Medical Research (CMR)
o Asylum wards where dysentery was widespread where used as research settings to find potential vaccines instead of battle fields- no one objected to performing experiments on impaired inmates
o Research trials were also performed on orphans and mentally retarded people
o Malaria research was done on inmates, they would infect them w/ malaria then given antimalarial therapies
o In another CMR study some people were given an influenza vaccine then subjected to the disease to see if they'd get it, the control group was not given the vaccine and was just exposed to influenza, some people suffered from lumps near the injection spots
o Principles of informed consent and risk- benefit calculations were largely ignored in these studies, voluntariness disappeared when the research had to do with helping to support the war
o When research didn't have an unambiguous social approval formal review and procedures for obtaining consent became necessary ( like w/ the gonorrhea study)
o Wartime environments undercut the protection of human subjects- they thought that all citizens ( including retarded people) should be doing their part to help fight the war
o Wartime promoted utilitarian over absolutist position- the greatest good for the greatest # of people
o Ethics of American research during WWII were utilitarian
o Utilitarian ethic continued to govern human experimentation b/c the benefits seems greater than the cost, no groups/ individuals opposed this ethic
• The article focuses on Henry Beecher's analysis of "Ethics and Clinical Research" which accelerated the movement that brought human experimentation under rigorous federal and institutional control in 1966.
• Beecher came up with 22 cases in which researchers adopted invasive or risky procedures without informing their subjects or seeking consent.
• Important questions: Were Beecher's 22 cases the work of marginal researchers? Was the mountain of regulations that followed an exaggerated response to a few unusual incidents? And what explains the investigators behavior?
o One answer has been to deny that the 22 cases fell within the mainstream of science. But this has been proven wrong formany of these cases took place in major university and government facilities (hospitals).
o A second response is the insistence that the researchers involved were working in an ethical vacuum because the basic principles of informed consent were as yet unformulated.
• Rothman uses the original articles on which Beecher based his 22 case examples as the sources for his analysis.
o Explains how human experimentation has a lengthy history. During the period before Beecher's publication, research ethics was merely discussed because medical ethics was not an active field and also because human experimentation was conducted by a handful of physicians whose subjects were themselves family or neighbors and whose aims were directly therapeutic for the subjects.
o Prior to Beecher's publication, as long as clinical research continued to be conducted on a relatively small scale and with therapeutic intent, research ethics wasn't subject to extensive investigation, debate or concern.
o The turning point in human experimentation in the U.S. was WWII and practices established during these years profoundly influenced researchers' behavior in the postwar era.
In 1941, the CMR (Committee on Medical Research) was established to plan and coordinated medical research.
o The CMR was concerned with creating antidotes to dysentery, influenza, venereal diseases, and malaria.
Researchers had a hard time locating suitable research sites since research on the battlefield wasn't allowed. Instead, asylum wards where dysentery was endemic were substituted as the setting of research with no objections to experiments on impaired inmates.
• These experiments, all of which were unsuccessful, produced serious side effects on subjects.
• Dysentery experiments also carried out on retarded residents of an Illinois institution and NJ colony for the "feeble-minded."
To research malaria vaccines (for back in 1941 malaria was debilitating and deadly and the Japanese controlled the quinine supply) researchers used psychotic backward patients in hospitals, prisoners in state penitentiaries and infected them with malaria.
Public response to such experiments was not to ask whether prisoners were able to give voluntary consent, but to congratulate them for demonstrating "to the fullest extent just how completely this [WWII] was everybody's war."
CMR also sought to create a vaccine for influenza, which created a great amount of disability among soldiers.
• Some researchers used hundred of residents from state facilities for the mentally retarded and correctional centers for young offenders as testing grounds for the influenza vaccine.
o Those who contracted the disease had serious side effects.
CMR also allowed researchers to conduct human experiments with prisoners in order to research into the prevention and cure of gonorrhea.
• Although consent forms were given to these prisoners (as opposed to subjects from the influenza, malaria, and dysentery trials), the document exaggerated the potential benefit of the research to the subjects.
• The exception that was presented by the gonorrhea studies indicates that if principles of informed consent and risk-benefit calculations were occasionally recognized, wartime demands usually obscured them.
Only when research didn't have ambiguous social approval (as with gonorrhea), formal review and procedures for obtaining consent became necessary.
In sum, the ethics of American research during WWII were utilitarian for it was based on the philosophy of doing the greatest good for the greatest number, even if the rights of some of these subjects were violated.
• Using mentally incompetent inmates was justified by the idea that all citizens should be doing their part in the wartime period and that if they had been capable of a momentary flash of competence, they would've participated in research that furthered the war effort. Hence, using them as research subjects didn't violate their interests.
• The utilitarian ethic continued to govern human experimentation even after the post-war period because of the war precedent, because the benefits seemed so much greater than the costs, and because there were no groups prominently opposing such an ethic.
o American researches and physicians didn't adhere to the Nuremberg Code.
• Conclusion:
o The revolt against researchers that continued to pursue a utilitarian ethic was fueled by Beecher's article in the 1960s as well as a new wariness about the fruits of scientific research and a general hostility towards authority.
o Federal regulations mandated the creation of institutional review boards to ensure that subjects had given informed consent and that risks did not outweigh the benefits.
o For the first time, decisions that that were traditionally left to the individual physicians came under collective surveillance

• Know the ethical considerations in the use of placebos, and the concept of 'clinical equipoise'. How do these concepts apply to international clinical research? See B&C and Emanuel et al.

Conditions for Ethical Clinical Research: (*Emanuel, Wendler, Grady)
1. Value
2. Scientific validity
3. Fair subject selection
4. Favorable risk-benefit ratios
5. Independent review
6. Informed consent
7. Respect for enrolled subjects
"Fulfilling all 7 requirements is necessary and sufficient to make clinical research ethical"

Clinical equipoise: On the basis of the available evidence, members of the relevant expert meical community are equally poised between the treatment strategies being tested in the RCT, because they are equally uncertain about, and equally comfortable with, the known advantages and disadvantages of the treatments to be tested (or the placebo being used).
o Certain properties that have often served, unjustly, as bases of distribution - gender, race, IQ, linguistic accent, ethnicity, national origin, social status. These properties are irrelevant, discriminatory, and based on differences for which the affected individual is not responsible.
o Fair-opportunity rule says that no persons should receive social benefits on the basis of undeserved advantageous properties (bc no persons are responsible for having these properties) and that no persons should be denied social benefits on the basis of undeserved disadvantageous properties
Properties distributed by the lotteries of social and biological life don't provide grounds for morally acceptable discrimination if people don't have a fair chance to acquire or overcome properties
(Rawlsian) To overcome disadvantaging conditions (whether biology or society or whether received through natural lottery or social lottery) that are not deserved, the rule demands compensation for disadvantages.
o Implications for access to health care
Requires that they receive the benefits needed to ameliorate the unfortunate effects of life's lottery
Persons with functional disabilities lack capacity and need health care to reach a higher level of function and have a fair chance in life
If they are responsible for their disabilities, they might not be entitled to health care service, but if not responsible, fair-opportunity rule demands they receive that which will help them reduce or overcome unfortunate effects
Raises questions to which underserved properties create a right in justice to some form of assistance?
Limited resources constrains implementation o this rule (as brought up by Libertarians). Draw a line between disadvantages that are unfortunate and disadvantages that are unfair.
o Probability of successful treatment (medical utility); age may be an indicator of the probability of surviving and benefitting from a treatment/operation; looking at QALYs (quality-adjusted life year) based on the quality and number of years of life that would be added by the intervention
o Norman Daniels— faced with a limited lifetime health budget, the "prudent buyer" would invest in elements of HC that would enhance the likelihood of reaching reasonable longevity rather than reserve funds to extend life at its end; more resources for younger people to maximize each person's chance of living at least a normal lifespan
o Alan Williams—"Fair innings" argument; considers a person's whole lifetime experiences and seeks equality; each person receiving the same level of HC but at different stages of life; requires discrimination against the elderly
o Callahan (361-7)—when a person has lived out a natural life span, medical care should not be used to resist death, but only to mitigate suffering; the government is obligated to help its citizens live out a higher quality of life of a natural lifespan but to not to indefinitely extend the length of their lives; need for cultural acceptance of dying and death and to stop fighting natural death at the end of life; the dying elderly should not consume a disproportionate share of HC costs at the expense of children etc.

Against:
o Stereotyping of the elderly
o Creation of conflict between generations
o Elderly didn't have access to technologies that are now available; and now they are denied them?
o B&C: proceed with caution! Age-based allocations of HC could be implemented in a just, beneficial way but in many countries they are unjust
o Norman Levinsky (p367-9)—medical care that extends life devoid of human qualities should not be undertaken, but this principle should apply equally to patients of all ages, not only to the elderly; allocate resources according to the probability that a patient will benefit rather than his/her age; actually, very small savings if we eliminated high-tech life procedures for the elderly
o Joseph Boyle (p370-5)—age should not be used as a standard for denying medical treatment; age does correlate with many of the factors which might make it reasonable to deny HC benefits to some people (expected benefit, equal use of HC over a lifetime) but it is theses factors, not age, which are relevant to fair rationing decisions; doesn't mean that elderly are automatically entitled to all resources of HC system though
For using alcoholism as a criterion for access to liver transplantation:

- Donor livers are a non renewable, scarce resource; this fact necessitates that distribution standards (may they even be discriminatory in nature) be set for allocating this resource and that these standards mandate that ARESLD patients receive donor livers only after ESLD patients are provided with them
- Allowing ARESLD patients to have the same priority on transplant waiting lists as ESLD patients would lead to a decline in public support for and approbation of liver transplants---thus, less organs will be donated, which will decrease the already scarce supply of donor livers; using alcoholism as a criterion would maintain public support so that organs continue to be donated
- Patients with ARESLD may resume consuming alcohol after a transplant and may develop ARESLD again, thereby wasting the liver.
- Alcoholism is a disease; appropriate treatment options are available to treat it. therefore, alcoholics should be held responsible for obtaining treatment that could very well prevent the development of ARESLD; if they were not responsible enough to seek treatment for their alcoholism, then they should be denied priority for liver transplants.
- Ethical principles upheld:
1) Under the principle of fairness, using alcoholism as a criterion is a fair and just way to allocate donor livers; because donor livers are scarce, it is fair to hold people responsible for their choices, such as not obtaining alcoholism treatment, and to allocate livers on this basis
a. Patients who develop ESLD through events out of their control should have higher priority in liver transplantations than people with ARESLD who failed to obtain or follow through with treatment for alcoholism.
2) Principles of distributive justice:
a. To each, similar treatment for similar cases: Patients with ARESLD are dissimilar to patients with ESLD since their liver failure was preventable; thus it is acceptable to treat them differently and to give them lower priority for liver transplants.
b. To each, treatment according to personal effort: Alcoholics can be held responsible for seeking treatment for their disease and consequently preventing ARESLD; if they did not make the personal effort to prevent ARESLD through treatment for their alcoholism, then they should be held responsible for that decision and be denied equal priority for liver transplants as patients with ESLD.
3) Greater utility can be obtained by granting patients with ESLD liver transplants before patients with ARESLD because it is more probable that the use of this scarce resource will be maximized if it is transplanted into an ESLD patient than if it were transplanted into an ARESLD patient.

Against using alcoholism as a criterion for access to liver transplantation:

- If patients with alcoholism are denied treatment for their "personal misconduct" then it
would only be fair to deny treatment to patients who have diseases due to their own
personal misconduct as well; however, this is not the case, so alcoholics should not be
discriminated in this way.
- Alcoholism is widely regarded as morally wrong and blameworthy; yet, this does not justify the categorical denial of liver transplants to patients with ARESLD. Excluding ARESLD patients from liver transplants based on the moral failing of the patient assumes that some level of moral virtue is required for a transplant and some level of moral vice disqualifies one from a transplant; however, determining what constitutes a moral virtue and vice and what rewards and penalties they deserve can seemingly appear to be arbitrary and not universal.
- Penalizing ARESLD patients by denying them transplants would be holding some groups arbitrarily to a higher standard than others.
- Denying ARESLD patients candidacy for liver transplants based on probable poor outcomes for this group compared to others is based on a false premise; alcoholics have been shown to do well after liver transplantations.
- The low survival rate of alcoholics after they have received a transplant is not a valid reason to exclude them from transplant candidacy; members of other groups who are known to have low survival rates are not excluded from transplant candidacy so neither should alcoholics.
- Ethical principles upheld:
1) Principles of distributive justice:
a. To each person an equal share: Denying alcoholics transplant candidacy would be an unequal distribution of a scarce resource. However, allowing patients with ARESLD and ESLD to have access to liver transplants would uphold equality.
b. To each person according to need: ARESLD and ESLD patients both need liver transplants for survival. Excluding one group from transplantations would unfairly be placing one group's needs over another's.
2) Principle of fairness
a. It is unfair to deny treatment to a group based on the circumstances of their personal misconduct or the moral blameworthiness of their actions. Including both alcoholics and ESLD patients for transplant candidacy is fair and just.
1. Health workers' duty to provide care during a communicable disease outbreak
• Workers should know ahead of time their duties and responsibilities during an outbreak
• Their safety should be protected at all times
• Insurance and death benefits should be provided to all workers' who are adversely affected while performing their duties
2. Restricting liberty in the interest of public health by measures such as quarantine
• Protocol should be developed for the implementation of restrictive measures that balance individual liberties with protection of the public from harm
• The public should be aware of the rationale behind the restrictive measures, the benefits of compliance and the consequences of noncompliance.
• Plans should be made to protect against stigmatization and to safeguard the privacy of individuals and communities affected by restrictive measures
• Measures to guarantee provisions and support services to those affected by restrictive measures should be implemented into the pandemic plans.
3. Priority setting, including the allocation of scarce resources, such as vaccines and antiviral medicines
• A clear rationale of who gets priority to health care services during a pandemic should be publicized.
• Stakeholders (staff, the public) should be included in determining what criteria to make resource allocation decisions.
• Formal mechanisms should be in place for stakeholders to present new ideas, to appeal or raise concerns about allocation decisions and to resolve conflicts
4. Global governance implications, such as travel advisories
• The WHO (World Health Organization) should be aware of the impact that travel recommendations will have on affected countries
• The developed world should continue to invest in improving the overall public health infrastructure in developing countries