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 (1) What makes an act morally right or wrong (a

question of conduct)?
 (2) What makes a person or something good or
bad (a question of value)?
 (3) How to draw the correct conclusion about
what we ought to do or what kind of person we
ought to be?
 (1) and (2) are theoretical/conceptual questions
and (3) is a practical question about moral
reasoning.

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Why Is Ethical Analysis Needed?
 Problems are not just technical
 How do we know which problems
are important?
 How do we know a good solution?

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Ethical Theory Alone Is Not
Sufficient

 Philosophical terms often are not

clearly defined
 Using ethical analysis to guide
decisions requires practice
 Moving back and forth between
cases and theory can help

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Three Categories of Ethical
Argument
 Consequences (outcomes):
 Utilitarianism
 Rights (starting points):
 Liberalism
 Virtues (character):
 Communitarianism

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Each Perspective Has
Unresolved Issues

 How do we measure
consequences?
 Which rights do citizens have?
 Who defines the community and its
values?

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 Utilitarianism
 Policies should be judged by their
consequences
 What matters is well-being of individuals
 All individuals count equally
 The best action is decided by adding up
the gains and losses to all individuals
 “The greatest good for the greatest
number”

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 It is better to be a human being
dissatisfied than a pig satisfied; better
to be Socrates dissatisfied than a fool
satisfied.
John Stuart Mill - Utilitarianism

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How Can We Measure Utility?

 Individuals evaluate their own

situation: subjective utilitarianism
 Experts devise an index to
measure everyone’s well-being:
objective utilitarianism objective
utilitarianism
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Subjective Utilitarian

 Ask consumers about their

“willingness to pay”
 Use data about prevalence, costs,
and prices to calculate costs and
benefits

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Problems with Subjective
Utilitarianism

 Suppose consumers are foolish

or uninformed?
 Does “willingness to pay” really
measure changes in well-being?
 How do we account for the fact
that the rich can pay more?

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Objective Utilitarianism

 Construct an index to measure health

(e.g., Disability-Adjusted Life Years)
 Calculate health losses for different
diseases
 Set priorities based on cost-
effectiveness

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General Problems with
Utilitarianism
 Concerned with aggregate
welfare not with distribution
 Lack of respect for individuals
 Can justify inequality
 Technical calculations can mask
values

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Liberalism
 Individualshave the capacity to make
moral choices about life
 Therefore, they are entitled to
respect to choose their own life plan
 Therefore, they have a right to
preconditions for such choices

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What Rights Do People Have?
 Negative rights - to be left alone,
to be free to choose, to speak, buy
and sell: libertarianismtarian

rights – to resources
 Positive
needed for a reasonable range of
opportunity: egalitarian liberalism
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Libertarians

 Right to control your own body

 Right to purchase health care
 Priority to market, with minimal
state limits on individual choice
 No redistribution by state

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Egalitarian Liberals
 Basic right to opportunity: health
itself
 Role of state to redistribute
resources to assure fairness
 Example: Right to AIDS drugs for
worst-off in society

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Problems With Liberalism
 What positive rights to citizens have in the
health care arena?
 Do we treat those who cause their own ill
health?
 What geographic scope for redistribution?
 Are universal rights another form of cultural
imperialism?

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Communitarianism
 Individuals live in society – not in
isolation
 A good society requires citizens
with “virtuous” character
 Society should instill virtue and
create a desirable social order

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Who Decides What Is
Virtuous?
 Each society decides for itself what
is virtue (relative
communitarianism)
 There is one definition of virtue for
all societies (universal
communitarianism)

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Problems for Relative
Communitarians

 How do we know the boundaries of

communities?
 How far can communities go to
suppress dissent?

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Problems for Universal
Communitarians

 Lack of tolerance for local or

minority cultures
 What happens when those with
conflicting visions meet?
 How do we know whose vision is
correct?

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Broader Question of
Justification
 Faith
 Intuition
 Logic
 The World
 There is no justification

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Mixed Positions
 Using more than one theory
 Principled construction of a mixed
ethical position – some examples:
 Utilitarian who respects some rights
 Egalitarian liberal sensitive to local
customs

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Implications (1)
 You cannot make health policy
without values
 Conflicts in values often occur in
making policy decisions
 Conflicts occur even “inside” a
theory because its implications
may be ambiguous

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Implication (2)
 Ethical analysis can help identify
implicit values in varying policy
positions
 Ethical analysis can help someone
clarify their own position
 Ethical analysis can increase
consistency, transparency, and
accountability

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That’s all, folks!

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