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Ethics in Public Health Leila Afshar MD. PhD of Medical Ethics Department of Medical Ethics Shahid Beheshti University of Medical Sciences Introduction Ethics v. Morality Ethics as a normative institution. Other normative institutions Ethics The word ‘ethics’ means the philosophical study of the moral values of human contact and the rules and principles that ought to govern it. The Levels of Moral Discourse Meta-ethics Normative Ethics Rules and Rights (Code of ethics) Cases (Casuistry) Meta- Ethics 1. What is the source of ethics? Religious answers: The divine will The divine law Secular answers: a. Universal sources(universalists): natural law, actual or hypothetical contract b. Relativist answers: one’s culture, one’s personal preferences, actual social contract 2. How do we know what is ethical? Religious answers: Revelation Scriptures Tradition(religious authorities) Experience and reason Secular answers: • Reason (Kant) • Experience and observation(Hume: experience of sympathy) • Intuition • Social agreement or contract Normative Ethics At this level the broad, basic norms of behavior and character are discussed. The key feature of these norms is that they are general. They apply to a wide range of conduct and character. Moral Agent Consequences Action Three questions of Normative Ethics Action Theory: what principles make actions morally right? Value Theory: what kind of consequences are good or valuable? Virtue Theory: what kind of character traits are morally praiseworthy? Action theory What principles make actions morally right? The answer involves some list of moral principles such as: beneficence, non-maleficence, respect for autonomy justice. will have to address the question of how to resolve the conflicts that arise among principles. Value Theory What kind of consequences are good or valuable? The real question here is what kind of things are intrinsically valuable? Among the standard answers are happiness, beauty, knowledge, and importantly for biomedical ethics- health. Virtue Theory What kind of character traits are morally praiseworthy? Virtues be understood as referring not to the actions, but to the people who engage in the actions. Benevolence vs. beneficence. Rules and Rights Code of Ethics Often rules and rights express the same moral duty from two different prospective. Rules are expressed from the prospective of the one who has a duty to act; rights claims from the vantage point of the one acted upon. How rigidity do rules apply? Legalism: there are no exception to the rules and rights. Rules of practice: rules specify practices that are morally obligatory. Exceptions are made only in very extraordinary circumstances. Situationalism: moral rules are merely “guidelines” or “rules of thumb” that must be evaluated in each situation. Antinomianism: every case is so unique that no rules or rights can ever be relevant in deciding what one ought to do in a specific situation. The Level of the Case Discussion begins with a case. Approaches: Casuistry or paradigm cases: similar cases should be treated similarly. Or if the relevant features are similar, then cases should be treated alike. Agree on what should be done in paradigm case and agree that the new case is similar in all relevant aspects. A Full Theory of Bioethics For the last decades of twentieth century, theorists defending the top-down approach and clinicians the bottom-up. More and more there is agreement that, what is critical is that, for a full and consistent approach to bioethics, eventually all four of these levels must be brought into “equilibrium”. It seems less and less important where one starts. One will move up and down the ladder of the levels of moral discourse. A stable equilibrium is necessary for a full and consistent position in bioethics. Ethical Case Analysis in Public Health 1. Screening: a. HIV b. Genetic 2. Population Control Screening Voluntary Compulsory Universal 1 2 Selective 3 4 Case of HIV 1) 2) Universal & Voluntary: Encouragement and choice Universal & Compulsory: Coercion Neither voluntary nor compulsory-universal screening is justified by current evidence. HIV infection is not widespread outside groups engaging in high-risk activities. Screening in groups or areas with low prevalence produces falsepositive. Universal screening is very costly and cost-ineffective. Must be repeated often. 3) Voluntary- selective screening In people with unsafe sexual practices Share needles in intravenous drug abusers Pregnant woman and newborns Unsolved questions: Who should be encouraged? Who should bear the cost? Pre- and post test counseling. 4) Compulsory-selective screening It can be justifiable whenever persons engage in actions or involved in procedures that impose risks on other who can not avoid those risks. Blood donation, sperm donation, organ donation Workplace? Prisons? Pregnant women Genetic Screening طرح کشوری غربالگری سندرم داون ارجاع تمام خانم های بارداربه مراکز معرفی شده توسط وزارت بهداشت غربالگری در سه ماهه اول ودوم بررسی سونوگرافیک جنین بررسی بیوشیمیایی خون مادر( مارکرهای چند گانه) محاسبه خطرسندروم داون معرفی به مراکز ژنتیک جهت آمنیوسنتزوتایید تشخیص معرفی موارد قطعی به مراکز قانونی جهت سقط درمانی پرداخت هزینه توسط خانم های باردار تقبل نکردن هزینه های غربالگری توسط بیمه ها. انجام ارزیابی ها از چه میزان اهمیتی برخوردار است .به عبارت دیگر اگر برای انجام دادن یا ندادن آزمایش ها طرف مشاوره قرار گرفتیم چه پاسخی بدهیم؟ ارزیابی فایده و خطر . .1آیا رضایت فرد برای انجام آزمایش آگاهانه و آزادانه خواهد بود؟ .2آیا صرف منابع نظام سالمت عادالنه هزینه خواهند شد؟ .3آیا اطالعات بدست آمده در دایره رازداری و حریم خصوصی افراد قرار خواهند گرفت؟ In advising patients about genomic testing be aware of : 1. 2. 3. 4. 5. the clinical limitations of testing, the risk of discrimination, the importance of informed consent, the importance of confidentiality, and the implications for relatives. The Ethics of Population Control Reproductive Rights Contraception Reproductive rights also means access to Assisted Reproductive Technologies (ART). Contraception The Malthusian Warning (1798) – die-back Paul Ehrlich (1960) - the resolute practice of population control. The critic of population control: Religious critics Feminist critics Cornucopian critics Leveling Off: The Demographic Transition Incentives and disincentives 1. 2. 3. What moral limits are there on the use of incentives and disincentives to manage population size? Which are preferable? How strong may they be? The case of India 1975-6 The Nazis used bronze, silver, and gold medals to reinforce large family size for Aryan (but not Jewish) women: four, six, and eight children respectively. Ceausescu’s Romania used a variety of harsh disincentives and penalties for abortion or failure to have an adequate number of children, set at five Singapore (1983) China’s one-child program Contraception mandates vs. family size ceilings While in practice contraception mandates and family size ceilings are often intertwined, they are conceptually different. Contraception mandates may alter the decisional structure of childbearing choices, but still recognize individual preferences in choices about family size; family size limits may impose a ceiling, but can leave it to the couple to determine how to prevent childbearing so as to stay within the limit. the question is which form of interference is morally more tolerable? Targeting Optimal Population Size: Fewer with More, or More with Less? Contraception vs. Planned parenthood long-acting reversible contraception, or LARC ARTs IVF Egg or Sperm Donation Embryo Donation Surrogacy از میان روش های کمک باروری ذکر شده کدام یک را از نظر اخالقی قابل قبول تر می دانید؟ چالش اخالقی اضافی که هر روش به بار می آورد چیست و چه کس یا کسانی از تبعات این اقدام تاثیر می پذیرند؟ ( کودک ،مادر ،اهدا کننده ،پدر ،خانواده و یا جامعه) [email protected]