Module 1: Introduction to Biomedical Ethics

Case of Baby Joseph

biomedical ethics
➢ examining “ethical problems in the medical and life sciences, including
genetics and biology, and in the provision of health care”

Arguments
➢ are ways of lending support to a conclusion by reasoning from other
claims.

Principles of Biomedical Ethics

1. Non-maleficence: do not cause harm to a patient
2. Beneficence: benefit the patient and reduce harm
3. Autonomy: respect the choices, preferences of patient
4. justice : promote and treat people equally

Clinical Ethics
➢ Involved with patient and
doctors
➢ Analysis of clinical medical
practice

Public health ethics

➢ Issues related to public
health, societal approach to
protecting populations
➢ Governments, populations
and subpopulations

Research Ethics
 ➢ Ethical analysis of medical research, which aims to ensure such research
protects the consent and wellbeing of participants

moral intuitions
➢ the thoughts that occur to you when thinking about these
cases—reactions or gut feelings about what is best to do. It might take
practice to clarify for ourselves what, exactly, our moral intuitions are
about a given case.

Moral philosophy
➢ the study of morality. Moral philosophers examine and reflect on what is
right or wrong, good or bad, and why.

Meta-ethics:
➢ When we say something is “meta” we usually mean it is asking higher
order questions.
➢ Meta-ethics, then, involves asking questions about whether morality can
or does exist, whether it is subjective or objective, whether moral
propositions can be true or false, what the nature of morality is, where
morality comes from, and so on.

Normative Ethics:

➢ Normative ethics is a branch of ethics that aims to determine how to act

morally and how to lead a moral life.
➢ Normative ethics involves creating ethical theories or systems that can
help us evaluate what the best course of action is, how to live a moral life,
or how to determine what is good.
 ➢ Normative moral theories aim to develop standards or norms from which
we can think about morality and what is good or bad.

Applied Ethics:

➢ Applied ethics is the study of specific, real-world problems to identify the

ethical issues that are involved in that scenario and make suggestions
about what we should do to remedy these issues.
➢ Sometimes in applied ethics, we might use normative moral theories or
moral principles to make arguments about what we should do in specific
scenarios.

But, as our textbook notes, applied ethics shouldn’t just be the direct
application of normative moral theories to individual cases. We should start
with the cases themselves, and then consider the ethical issues involved.

Normative claims

statements that express an evaluation or value judgment, beyond merely

describing something. These can be identified by words like ought,
should/shouldn’t, right/wrong, good/bad.

➢ “My friend is a good person.”

● “We should reduce red meat consumption to help address climate
change.”
● “Beyonce is the best singer of all time.”
● “The government has an obligation to provide affordable housing.”

Descriptive claims

are statements that describe something. Expresses an understanding of the way

in which something is or could be. There is no evaluation or judgements made.
“Freddy Mercury was the lead singer of Queen.”

● “My car is red.”

● “Stephen Harper was prime minister of Canada from 2006 to 2015.”
● “The boiling point of water at sea level is 99.97°C.”

These claims often require empirical investigation or verification: we might

have to go outside to verify the fact that my car actually is red.

Normative theories
Utilitarianism: consequentialism holds that a morally right action is one that
promotes good consequences, the morality of an action is determined by the
effect that it has

Utilitarianism is concerned with the outcome of actions to determine whether

those actions are morally good -beneficence and nonmaleficence grounded in
utilitarianism

Deontology: defines a morally right action not in terms of the consequences

that the action brings but instead focuses on the intentions or reasons that
guide the action

Virtue ethics: plato and aristotle- what does it mean to be a good person
 Module 2: Adults and Decision Making
Key terms:
autonomy: as the capacity to be self-determining.
autonomous person: makes decisions, choices, or determinations for
themselves is important—to count as autonomous, these decisions cannot be
coerced or unduly influenced by external forces,
Informed consent: obligates a physician to discuss medical procedures
(including treatment options, medication, surgeries, therapies, preventative
interventions, and so on) and risks and benefits of those procedures with a
patient,

Shift towards patient-centered care

● Medical decision making placed in the hands of patients or substitute decision

makers
● Patients know what is best for themselves
● Substitute decision makers can include parents or spouse
● Autonomy is the philosophical foundation of patient-centered care
● Autonomy defined as the capacity to be self-determining
● Autonomous decisions are informed by values, desires, beliefs, and goals
● Autonomous decisions cannot be coerced or unduly influenced by external
forces
● Properly autonomous decisions should be respected
● Debate on what it means to be properly autonomous
● Competence is a key factor in autonomous decision-making
● Balancing respect for autonomy and protection from harm in assessing patient
autonomy and competence

Autonomy and informed consent

● Informed consent is a primary safeguard in medicine

● Patient's decisions should be respected when properly autonomous
● Patients bring knowledge of subjective aims and values to the physician-patient
encounter
● Informed consent obligates physicians to discuss procedures, risks, and benefits
with patients
● Patients can consent or withhold consent based on their best interest and values
 ● Informed consent protects patient autonomy and is essential for ethical
treatment
● Secondary purpose of informed consent is to protect healthcare professionals
from legal liability

Buchanan and Brock

● Buchanan and Brock argue that no single standard of competence can be

adequate
● Competence was one important element of autonomous decision making
● Properly autonomous decision-making is the main question in determining
informed consent
● Competence includes capacities for communication and understanding,
reasoning and deliberation, and a set of values or conception of what is good
● Patient must demonstrate adequate abilities in each category to be shown as
competent

Balancing in Autonomy and protection

● Balancing two important values in informed consent: promoting and protecting

patient's well-being, and respecting patient's autonomy or self-determination
● Two possible errors in balancing these values:
○ Error 1: Failure to protect a patient from harmful consequences of their
decision when it's due to defects in their capacity to decide
○ Error 2: Failing to permit a patient to make their own decisions and giving
their right to someone else, despite having the capacity to decide
● Striking an appropriate balance between well-being and autonomy to minimize
errors
● Ethical deliberation required to determine the relative weight of these values
● Competency levels can vary depending on the situation
● Patient's competence to consent to a treatment does not imply competence to
refuse it, and vice versa
● High levels of competence vs low levels. E.g high level of competence required
when patient refuses a simple appendectomy, or low level, patient consents to
lumbar puncture

Freedman's Argument

● Freedman's account of competence and informed consent: choice must be

responsible and voluntary
 ● Balancing well-being and autonomy in medical encounters
● No fail-safe procedure to evaluate competence, requires examination of each
case
● For freedman, patient must informed so that a responsible decision can be made
● Informed consent involves giving patient enough information so that they ca
make an informed decision; must inform patients to ensure that their decisions
and choices are responsible ones

Freedman vs. Buchanan and Brock

● Differences between Freedman's account and Buchanan and Brock's account

● Freedman's view on necessary information for informed consent
● Criticism of burden of providing all information
● Information needed for the purpose of the decision
● Importance of being informed for responsible decision-making
● Informed consent requires enough information for expectations, alternative
options, and relevant
● Why must the patient be informed? Put that way, the answer is
immediately forthcoming. The patient must be informed so that he will
know what he is getting into, what he may expect from the procedure,
what his likely alternatives are—in short, what the procedure…will mean,
so that a responsible decision on the matter may be made” (65).
Module 3: Conflict about medical treatment

Introduction

● Mr. Rasouli's case is important for biomedical ethics

○ Conflicts about treatment in ICUs are complex
○ Prognosis and likelihood of recovery can be difficult to assess
○ ICU beds are a scarce resource
● Should a scarce resource be given to a patient with a poor likelihood of
recovery?

Medical futility: proposed as a way to limit patient demands for treatmentespecially

when those treatments would not help the patient’s condition.

● Lawrence Schneiderman and colleagues investigate patient autonomy and the

obligation of physicians to provide requested treatments
● They argue that if a treatment is deemed futile, it is not obligated to be
presented or provided
● Argument: “If an intervention is judged to be futile, the duty to present the
intervention as an option to the patient or the patient’s family is mitigates or
eliminated” (76).
● if a requested medical treatment or procedure is deemed to be futile, a health
care professional is not obligated to present that procedure as an option, nor are
they obligated to provide or perform the requested procedure.

● Health care professionals may conflate the notions of effect and benefit in
medical interventions
● The goal of medical treatment is to benefit the patient as a whole
● Effect is a mere change, while benefit improves the patient's prognosis, comfort,
well-being, or general health
● Schneiderman argument: A medical intervention that fails to provide benefit
should be considered futile
● Medical futility is an action that cannot achieve the goals of benefiting a patient,
no matter how often repeated
● then a medical action that fails to benefit a patient, no matter how often the
action is performed, should be considered medically futile.
● Futility is not equivalent to impossibility, implausibility, or hopelessness
Scheneiderman et al. argument to medical futility

● Schneiderman et al distinguish between quantitative and qualitative aspects of

futility (WATCH VIDEO)
● Futility can refer to the unlikelihood of an event happening or the quality of the
outcome
● Patient input and perspectives should still be considered in evaluating
qualitative futility
● Informed consent and ongoing dialogue with patients are still important
● Physicians may have grounds for exceptions to providing futile procedures
on compassionate grounds
● Physicians are not morally obligated to provide futile procedures
● Exceptions should not impose undue burdens on other patients, healthcare
providers, or the institution

Moral Obligations

● Moral obligations and duties in the context of medical treatments

○ Moral obligations are actions that a person is required to do based on
moral reasons or arguments
○ Permissible actions are allowed but not required
● Medical futility and the use of futile treatments
○ Physicians are not morally obligated to provide futile medical treatments
(SCHNEIDERMAN ARGUMENT)
○ Patients cannot demand futile treatments
○ Physicians may be permitted to provide futile treatments, but it is a
weaker position

Truog et. al

● Ethical arguments against using the concept of medical futility

○ Response to Schneiderman et al's arguments by Truog et al
○ Medical futility hides ambiguities and threatens its legitimacy as a
rationale for limiting treatment
● Categories of criticisms against medical futility by Truog et al
○ Problems of value and problems of probability
● Cases where medical futility is often used
○ Patients in a minimally conscious or persistent vegetative state
○ Debates around CPR or other forms of resuscitation
○ New and emerging organ-replacement technologies
● Values and pluralism in society
○ Pluralistic society recognizes a plurality of valid conceptions of what is
valuable in life
○ Different values can be adopted, and all are equally valid
● Criticisms of Schneiderman et al's quantitative aspect of futility
○ Arbitrary suggestion of using the last 100 cases to determine futility
○ Lack of solid reasoning for choosing 100 cases
○ Variation in patients' conditions and context affects judgments of futility

● Difficulty in determining the probability of futility in a given case

○ Patients' conditions and context play a role in assessing futility
● Reason for abandoning the notion of medical futility
○ Determining the probability of futility is too difficult
● Criticisms of Schneiderman et al's suggestion for determining futility
○ Lack of solid reasoning for choosing a specific number of cases
○ Factors like age, etiologic organism, and coexisting illness should be
considered in assessing futility

● Truog et al argue against the concept of medical futility developed by

Schneiderman et al
○ Problems with probability and ethical issues surrounding resource
allocation
● Rejecting medical futility does not mean endorsing unrestricted patient
demands for interventions
○ Providers oppose such demands due to a sense of wrongness
○ Avoid unilateral, provider-initiated declarations of futility
● Patients and healthcare professionals may disagree on the best treatments
● Truog et al suggest weighing different values in cases of conflict
● The notion of futility fails to provide an ethically coherent ground for limiting
life-sustaining treatment
● Summary of what has been learned in the module
● Application of concepts and arguments to a case study

● Truog et al argue against the use of medical futility as a concept

● Problems with probability and values
● Weighing different values in cases of conflict
Final conclusion

➢ does this mean they have that absolute right to demand any kind of medical
intervention they want?
➢ Truog et al argue that the answer to the last question is no: they say, “[o]ur
rejection of futility as a useful concept does not imply that we endorse patients’
unrestricted demands for interventions…

Module 4: MAID

Medical Assistance in dying

● Different names for medical assistance in dying: euthanasia and assisted

suicide
● Definitions of euthanasia and assisted suicide
○ Euthanasia: medical professional administers lethal injection to end
patient's life
○ Assisted suicide: medical professional provides means for patient
to end their own life
● Distinctions between active and passive forms of euthanasia
○ Passive euthanasia: withholding or withdrawing life-sustaining
treatments
○ Active euthanasia: administering lethal agent to end patient's life
● Distinctions between voluntary, non-voluntary, and involuntary
euthanasia
 ○ Voluntary euthanasia: done with patient's expressed and informed
consent
○ Non-voluntary euthanasia: done without patient's consent, but
with family consent
○ Involuntary euthanasia: done contrary to patient's request or will

Eligibility for MAID

● Eligibility criteria for medical assistance in dying in Canada

○ Eligible for health services funded by federal government or
province/territory
○ At least 18 years old and mentally competent
○ Have a grievous and irremediable medical condition
○ Make a voluntary request for MAiD without outside pressure or
influence
○ Give informed consent to receive MAiD
● Changes in eligibility criteria and safeguards for MAiD in 2021
● Statistics on MAiD in Canada
○ Total number of MAiD deaths in 2021: 10,064
○ Most common underlying medical condition: cancer
○ Common reasons for pursuing MAiD: loss of ability to engage in
meaningful activities, loss of ability to perform daily living
activities, inadequate pain control, loss of dignity, etc.

Expert Panel view on MAID

● Expert Panel from the Royal Society of Canada argues in favor of

legalizing MAiD
● Ethical values and social consensus on MAiD
● Importance of individual autonomy in Canadian society
● Informed consent as a mechanism to protect patient autonomy
● Autonomy and informed consent in relation to MAiD
● State's role in providing institutional frameworks for autonomous lives
and protecting important choices
● Constitutional commitment to individual autonomy as a basis for the right
to choose the time and conditions of one's death

Conclusion of Expert Panel argument for MAID

 ● Conclusion that autonomy yields a prima facie right to choose the time
and conditions of one's death
● State's obligations to remove obstacles to living an autonomous life and
protect important choices
● Constitutional commitment to individual autonomy supports the right to
request assistance in dying
● Prima facie right: a right that holds at first glance but can be overridden
by other considerations
○ Contrasted with absolute rights, which hold in every case
● Prima facie right to choose conditions of death and request medical aid in
dying
● Difference between moral rights and legal rights
○ Moral rights based on moral principles or standards
○ Legal rights established by legal principles, court decisions, laws, or
constitutional documents
● PRIMA FACIE CAN BE OVERRIDDEN TO LESS THAN FULLY COMPETENT
INDIVIDUALS
● Moral rights can support entitlements even without legal protections
● Rights place limitations or constraints on actions towards others
● Moral and legal rights can overlap, as seen with freedom of expression in
Canada

Trudo Lemmens argument for MAID

● Moral right to MAiD does not necessarily translate to a legal right

● Conflict between autonomy and protecting vulnerable members of society
● Concerns about designing protective institutional mechanisms for MAiD
● Fear of administering MAiD to less than fully competent patients
● Trudo Lemmens argues for a cautious approach to legalizing MAiD
● Two possible interpretations of the Supreme Court's decision in Carter v
Canada
○ Narrow interpretation: exceptional regime for MAiD, limited to
end-of-life patients
○ Broad interpretation: wider access to MAiD based on general
criteria for eligibility
● Other countries like the Netherlands and Belgium have a broader
approach to MAiD
 ● Lemmens raises concerns about access to MAiD in Canada and argues
for a narrower model
● Lemmens discusses worries about access to MAiD in Belgium's case
● Empirical slippery slopes: concerns about undesirable consequences and
ineffective safeguards
● Policies and regulations surrounding MAiD in Canada becoming
increasingly vague

Slippery slope argument for MAID

● Slippery slope argument: Vague criteria for MAiD can lead to increases
in life-ending acts in morally problematic circumstances
○ Concerns about protecting the vulnerable
● Vague eligibility criteria can open the doors to controversial cases of
euthanasia
○ Requests for MAiD from mentally ill individuals
■ Belgium legislation permitted MAiD for mental suffering
■ More strict legislation introduced for mental suffering cases
■ Wide variety of psychological conditions involved
● Controversy surrounding MAiD in cases where mental health is a major or
only factor driving a patient's request
○ Difficulty in assessing competence
○ Challenges in determining the effectiveness of treatment for mental
health suffering
○ Vagueness of diagnostic criteria for mental illnesses

Summary

● Canada's process of permitting MAiD requests in cases where a patient's

sole health condition is a mental illness
● Concerns about the vulnerability of people with mental illnesses
● Additional reasons for or against allowing MAiD for mentally ill patients
● Controversial cases of requests for MAiD from people whose social
circumstances result in ill-health
● Broad definition of health includes social well-being
● Impact of social determinants of health on requests for euthanasia
 ● Lemmens argues that social well-being factors should not enable access
to physician-assisted death
● Need for more safeguards in MAiD decision-making process
○ Independent assessment of requests
○ Specialized panels to ensure all other options have been exhausted

Module 5: Ethics of abortion

Abortion Procedures

➢ Abortion is a medical procedure that terminates a pregnancy by removing an

embryo or fetus.
➢ Two common abortion procedures:
○ The abortion pill (Mifegymiso): Combination of mifepristone and
misoprostol.
■ Mifepristone blocks the effect of progesterone, needed for
pregnancy to continue.
■ Misoprostol causes contractions of the uterus and relaxation of the
cervix.
■ Can be used up to 11 weeks after the first day of the last period.
○ Clinical or surgical abortion: Internal medical procedure performed in a
clinical setting.
■ Health care professional provides pain medication and uses dilator
sticks to open the cervix.
■ Thin tube inserted through the cervix into the uterus to remove
pregnancy tissue.
■ Procedure takes 5-10 minutes, followed by recovery for an hour in
clinic.

Facts about Abortion

● Abortion is safe with low complication rates (97.7% have no complications).

● 52% of all abortions are had by individuals between the ages of 20 and 29.
● CONSIDERED MEDICAL PROCEDURE

Abortion in Canada
 ● Abortion is legal in Canada with no legal restrictions across all provinces and
territories.
● Access to abortion is not always reliable, especially for those in rural settings
and some provinces/territories.
● Discussion on increasing access to abortion in Canada.

US Supreme Court Decision

● In June 2022, the US Supreme Court overturned Roe v Wade, protecting the
right to request and obtain an abortion.
● Decision made in the case of Dobbs v Jackson Women's Health Organization.

Don Marquis's Argument

● Don Marquis argues that abortion is morally wrong in almost all cases.
● Moral permissibility of abortion depends on whether a fetus has moral standing.
● Marquis believes fetuses have moral standing, making it wrong to end their lives.

Standard Arguments for and against Abortion

● Anti-abortion arguments: Life begins at conception or fetuses possess

characteristics that make them human.
● Pro-abortion arguments: Fetuses are not persons in some way.
● Impasse between the two positions, with anti-abortionists claiming pro-choice
principles are too narrow and pro-choicers claiming anti-abortionist principles
are too broad.

Marquis's Alternative Account

● Marquis proposes a more theoretical account of the wrongness of killing.

● Gives an alternative account of what makes killing wrong to resolve the abortion
controversy.

Marquis's Argument on the Wrongness of Abortion

● Marquis argues that abortion is morally wrong based on the wrongness of killing.
● Deprives the human of a future like ours; deprives them from experiences that
they could have faced in the future

Potential Objections to Marquis's Argument

● One objection is that fetuses lack the ability to value their futures, which is
essential for the value-of-a-future argument.
Marquis argument

● Marquis's response to the objection that infants do not have the cognitive ability
to value their future
○ Marquis argues that a person's future can be valuable even if they
themselves do not value it
● Potential objection to Marquis's argument regarding contraception
○ The argument: contraception prevents the actualization of a possible
future of value, therefore it is wrong
○ Marquis's response: his argument does not imply that there is an
obligation to maximize the number of futures-like-ours
○ It would be nearly impossible to determine what is harmed by
contraception, making it arbitrary to say it is wrong
○ The immorality of contraception is not entailed by the loss of a
future-like-ours argument because there is no nonarbitrarily identifiable
subject of the loss in the case of contraception
● Comparison between abortion and contraception
○ Abortion involves the identifiable subject of the fetus losing a
future-like-ours
○ Contraception does not have a nonarbitrarily identifiable subject of loss

Littles argument

● Margaret Olivia Little's article focuses on the moral status of the fetus and the
unique nature of pregnancy
● Ignoring the fact that gestation takes place inside someone's body leads to a
separate view of fetuses
● Little argues that the more interesting ethical concerns about abortion are
related to the responsibilities a person has towards the fetus
● Little's article focuses on the duties a person might have to gestate a fetus if
they find themselves pregnant
● Moral obligations/duties are stronger requirements to act compared to
permissible actions
● Little explores the duty to continue gestating when one finds themselves
pregnant
● Understanding and appreciating the nature of gestation as an intimacy is crucial
in examining this duty
Littles argument:

● Little's paper makes meta-philosophical claims about the nature of philosophy

and its approach to abortion
● The political and ethical discussion surrounding abortion lacks theoretical
resources for understanding pregnancy and gestation
● Most moral theories view people as separate individuals, which might not be
suitable for analyzing pregnancy and gestation
● A more accurate account of the nature of pregnancy and gestation is needed to
better contemplate the ethics of abortion
● Pregnancy is described as an embodied experience of being inhabited,
occupied, and physically intimate
● The intimate nature of pregnancy determines the harms and responsibilities
involved in the ethics of abortion

Littles argument

● Bans on abortion force women and pregnant people to continue gestating a

fetus
○ This violates their liberty and autonomy
● The question should not be whether women have a right to abortion, but when it
is morally permissible to exercise that right
● A clearer account of the ethics of intimacy and parenthood is needed to
determine when it is morally permissible to have an abortion
● Little argues that the woman or pregnant person's conception of their
relationship with the fetus determines whether there is a duty to gestate
● This raises concerns about subjectivity and the moral status of the fetus
● Little's argument is not concerned with the moral status of the fetus
● It is difficult to determine the correct conception of the gestator-fetus
relationship
● The biological component of pregnancy alone does not create a duty to gestate
● There is no one "correct" relationship between a pregnant person and a fetus
● Personal relationships and individual circumstances are crucial in determining
the permiss
● Overall, her point is that particular facts about personal relationships play an
important role in thinking about whether and when it is permissible for a woman
or pregnant person to get an abortion.
Module 6: Procreation and child reading
PGD testing
Canada allows patients and their doctors to select which embryos to implant
based on its genetic makeup for medical reasons

Julian Savulescu
➢ argues that you would be morally obligated to choose the healthier
embryo, the one without the genetic predisposition to asthma.
➢ Savulescu argues that the results of such PGD tests, including those that
currently exist for things like genetic health conditions and those that do
not yet exist for things like intelligence, should be used in making
decisions about which embryos to implant in IVF.
➢ His thesis is that “we have a moral obligation to test for genetic
contribution to [disease and] non-disease states such as intelligence
and to use this information in reproductive decision-making” (40).

Moral obligations/duties
➢ as something that a person is required to do, given some moral reason or
argument.
➢ Savulescu develops his argument in favor of the moral obligation to
choose the healthiest offspring using a principle that he calls procreative
beneficence. This principle holds that we should use genetic testing to
select embryos or offspring that do not have disease genes and have the
most desirable non-disease genes.
➢ We are also morally obligated to select future offspring based on which
are most likely to live the best possible life.
➢ Savulescu considers the best life to be the life with the most well-being.

Hedonistic theories: what matters for well-being is the quality of our

experience, e.g., that our experiences are pleasurable.

Desire-fulfillment theories: what matters is the degree to which our desires

are satisfied.

Objective list theories: these theories hold there are certain good activities for
everyone, e.g., achieving worthwhile things, having dignity, having and raising
children, gaining knowledge, developing our talents, appreciating beauty, etc.
What matters is whether or not we do these activities in our lives.

Here, Savulescu appeals to each of the theories of well-being described above

to say that all of these views would support his conclusion we should select for
higher intelligence, because intelligence seems to promote well-being:

If we think that well-being matters (an assumption Savulescu thinks is

uncontroversial), then we should follow the principle of procreative
beneficence to select for the offspring that would have the best possible life
via PGD for disease and non-disease genes.

Savulescu notes that two principles are in conflict in these kinds of examples are
the principle of procreative beneficence and the principle of procreative
autonomy
Savulescu concludes that we might protect procreative autonomy and allow
parents to select for certain disabilities, for example, if parents have good
reason to do so.

Gedge argument
➢ Gedge considers this last question. In particular, she considers arguments
made by many people with disabilities, who claim that “testing for
‘healthy’ embryos and the conceptualization implicit without it not only
stigmatize[s] disabled persons as deviant, but send[s] a message that
their lives are not worth living or that they are not welcome” (44).
➢ Gedge argues that the practice of PGD and PND is symbolically
harmful. We will break down what she means by symbolic harm along
with her argument on how PGD and PND constitute this kind of harm
towards disabled people.
➢ Gedge calls this view expressivism, as it criticizes the attitudes expressed
by the practice of PGD and PND. Expressivism claims that PGD and PND
“sends a message that devalues and poses a threat to persons with
disabilities” (44).

Gedge holds that expressivism has two components:

1. There are consequentialist harms associated with the lower status assigned
by the practice of PGD and PND, including threats of unwanted interventions,
increased discrimination and reduced service to disabled people.

2. There are also symbolic harms associated with PGD and PND, which are
derived from the meaning of the practices (rather than their effects).

PGD and PND devalue disabled people in two ways:

1. By depicting disabled people in a way that is inconsistent with their

proper moral status; and/or,
2. By unjustly positioning disabled people as subordinates.

Proper moral status: the status we have automatically, merely by being

human persons; this requires others to recognize us as persons with the
corresponding moral status.

De facto moral status: this status reflects the recognition we actually receive
in our societies and the actual degree of empowerment and ability to exercise
our moral rights, liberties, etc.

Module 7: Ethics and Indigenous peoples

health
colonialism
➢ as the process of European settlement, dispossession, and domination
over other parts of the world beginning in the fifteenth and sixteenth
centuries
➢ involves the use of violence and settlement to take control of land,
peoples, and resources to economically advance the empire, sometimes
through government enacted policies (see Honouring the Truth,
Reconciling for the Future, TRC 2015).

TRC
“[c]olonialism remains an ongoing process, shaping both the structure and the
quality of the relationship between settlers and Indigenous peoples” (2015, 45).

Political philosophy
➢ is a branch of philosophy interested in investigating the nature and
moral justification of the state/governments, policies, liberties/rights,
property, law and its enforcement.

Bourassa, Mckay-Mcnabb and Hampton

➢ examines oppression experienced by Indigenous women as a result of the
Indian Act in Canada. In particular, they examine how the Indian Act is
tied to worse health outcomes for Indigenous women.
➢ What the authors argue is that colonialism, along with sexism, racism, and
other forms of oppression, systematically deny Indigenous women access
to things that influence positive health outcomes, including various social
determinants of health.
➢ l argue that people can experience multiple forms of oppression. They
are that “[w]omen who bear their ‘otherness’ in more than one way suffer
from multiple oppressions” (280). Women who experience not only sexism,
but also racism and other forms of oppression (like ableism, homophobia,
etc.) are more vulnerable to assaults on their well-being and health.
Because Indigenous women, under colonialism, experience sexism as well
as racism, Bourassa et al argue that their health might be impacted more
than if they experienced just one form of oppression.
➢ As Bourassa et al argue, the Act adopted sexist standards of status,
where status was determined by male lineages. Bourassa et al explain
 that women with Indian status who married non-Indian men lost their
status. It is important to note that Bourassa et al are not arguing that the
Indian Act did not also have negative effects on Indigenous men.
➢ The sexist underpinnings of Indian status in the Indian
Actdisenfranchised and alienated First Nations women from their
culture and communities. Bourassa et al note that “between 1876 and
1985, over 25,000 women lost their Indian status and were forced to
leave their communities” (282) due to how the Indian Act defined Indian
status.
➢ Bourassa et al argue that we cannot study health inequalities
experienced by Indigenous women without recognizing the impact
colonialism, sexism, and racism has on their health and their access
to health care services.

TRC
➢ defines reconciliation in terms of “establishing and maintaining a
mutually respectful relationship between Aboriginal and non-Aboriginal
peoples in this country” (2015, 6). Reconciliation, we’ve seen, depends on
truth: “there has to be awareness of the past, acknowledgement of the
harm that has been inflicted, atonement for the causes, and action to
change behavior” (2015, 6-7).

The goals of the Calls to Action

➢ to help advance reconciliation, which, recall, is defined as “establishing
and maintaining a mutually respectful relationship between Aboriginal
and non-Aboriginal peoples in this country” (Executive Summary 2015, 6).
Indeed, the Calls to Action begins with the following statement made by
the Commission: “In order to redress the legacy of residential schools and
advance the process of Canadian reconciliation, the Truth and
Reconciliation Commission makes the following calls to action” (2015, 1).

Module 8: Public Health

Public health initiatives are often preventative and protective.

➢ This means that the goal of public health is to prevent populations from
becoming sick.
 ➢ This is a public health policy because it aims to prevent and protect
people from becoming seriously injured or dying in car accidents.
Governments implemented policies that required seatbelts given evidence
that seatbelts helped to drastically reduce the number of serious injuries
and deaths in car accidents. These policies aim to protect not just discreet
individuals, but entire populations.

Herd Immunity
➢ Herd immunity is defined as a threshold of immunity, where a large
portion of a population is immune to disease infection, which in turn
provides indirect protect from disease to those who are most vulnerable.
➢ One way to achieve herd immunity is through vaccination—but to do this,
it is required that a large percentage of the population vaccinate
themselves. This requires large-scale collective cooperation on the part
of many people. One of the most effective ways to achieve this kind of
large-scale cooperation is through policies enacted by governments
(often, provincial or federal ones).

Brennan

➢ thinks the answer to this question is yes. His thesis is as follows: “I will
argue that even libertarians can and should endorse mandatory, that is,
government-enforced, vaccinations” (263).
➢ Libertarianism, a term we will define in more detail, is a political
philosophy that strongly opposes infringement on individuals’ right to
decide how to live their lives. It is a political philosophy that is one of the
strongest defenders of peoples’ right not to be coerced, even if that
coercion would benefit others or society as a whole.
➢ If we can defend mandatory vaccination policies from the perspective
of a libertarian—who thinks there is little justification for coercion, even
in cases where such coercion would benefit others or the society as a
whole—then we would have a very strong justification of mandatory
vaccination. 4

Libertarianism
 ➢ is a political philosophy that emphasizes peoples’ negative rights.
Negative rights can be generally defined as freedom from certain
things, including freedom from state interference with their decisions and
liberty. In this sense, libertarians value individual autonomy as well.
Brennan argues that any kind of libertarian generally holds the view that
individuals are endowed with an extensive set of strong rights against
interference in their personal and economic decisions (264).
➢ The state cannot use coercive measures, or interference on individuals’
lives, to ensure that people do the right thing in every situation.
Elsewhere, Brennan writes that a libertarian “believes[s] that we must
respect adults’ rights to make stupid, self-destructive choices” (2018,
38-39).

Clean Hands Principle

The clean hands principle can justify governments using coercion to mandate
vaccination for children. This principle justifies government coercion to avoid
collectively harmful activities or activities that impose an unacceptable risk of
harm. Refusing vaccines, Brennan argues, constitutes a collectively harmful
activity that imposes an unacceptable risk of harm. The justification for this
policy is not paternalistic (e.g., enforcing vaccination for individuals’ own good),
but instead is grounded in the fact that individuals can legitimately be stopped
from participating in collectively harmful activities, like in the examples of the
sharp-shooters or the reckless astronauts.

Mark Navin
➢ will argue in favor of ‘nudging’ people to vaccinate their children or
themselves. Nudging is a way of altering what is called the “choice
architecture” of people in order to (more or less gently) push them
towards choosing a better option. In the case of vaccination, this might
look like a family physician treating routine vaccination as the ‘default’
option or as providing children with gains. The latter option might involve
emphasizing the benefits of vaccines to nudge parents towards choosing
to vaccinate.
➢ This is because nudges seem to be paternalistic, because they might get
an individual to do something that is in their best interest, which they
 might not have chosen for themselves if the “choice architecture” were
not interfered with.
➢ Nudging is a concept in behavioural economics, decision making, social
psychology, and philosophy that proposes we can adapt the design of
environments where people make decisions in ways that influence the
decision-making and behaviour people
Nudging is one method of trying to achieve compliance with public health
policies, including vaccination. Navin gives three initial reasons that could
justify the use of nudging in the context of vaccination:

● Nudges are effective;

● Nudges are efficient; and,
● Nudges are less coercive than other methods of increasing vaccine
compliance

Navin argues that we might be able to justify nudges, even ones that seem
to violate autonomy, if we can show that infringements on autonomy are
outweighed by the benefits brought about by the nudge

➢ Navin gives several arguments in favour of the use of pedatric vaccination

nudges. These arguments appeal to two things: first, the interests of the
individual children and not becoming ill, and second, the interests of others in
not contracting a vaccine-preventable illness.
➢ Interestingly, some libertarians think that this is a permissible form of
paternalism. A libertarian could argue that nudges are permissible forms of
paternalism, even when done by the government, because ultimately the
individual still has a choice.

Module 9: Right to Healthcare

Bill 60 “your health act”-

 - Facility costs: defined as a charge or payment for a service or operating
cost that 1: supports or assists an insured service and 2: is not part of the
insured service
- Integrated community health service center: defined as a health
facility where one or more members of the public received services in
respect of which facility costs are paid
- The Act permits private clinics (act refers to as integrated community
health services centers) to charge patients for accessing services
- These centers run independent from hospitals or government health
agencies
Pros
- Help clear backlogs and long wait lists
Cons
- Slippery slope affect leading to a two-tier health care system where those
wealthier have greater access to private services
- Risks in losing physicians, nurses and healthcare professionals in public
health care settings

Healthcare in Canada
- Publicly funded through taxation and businesses
- Both provincially and territorially regulated with some support from
federal government
- The federal government assists provinces and territories with
establishing national standards for health care systems through the
Canada Health Act
- The Act states that the primary objective is to “protect, promote and
restore the physical and mental well-being of residents of Canada and
to facilitate reasonable access to health services without financial or
other barriers
- Ontario has OHIP established by the ontario Health Insurance Act
- This Act provides insurance “against the costs of insured services
on a non-profit basis”
- Anyone who is a resident in ontario is entitled to apply for OHIP
- OHIP is considered a single-payer health care system because a
single entity, the provincial government, pays for most services
Moral Right - is a right that people have in virtue of some moral principle or
standard
- Based on the nature of being human regardless of age, gender, race,
citizenships, etc.
- Universal, held equally, often unchanging aka natural or human rights

Legal Right - is a right that people have that has been established by legal
principle, court decisions, laws or regulations
- Based on our society’s or government’s laws or customs
- Legal rights can change

US President’s Commission for the Study of Ethical Problems in Medicine

Main Question: how ought health care be distributed?

Conclusion of report by the Commission:

➢ social obligation to provide everyone with an adequate standard of health care

without excessive burden

Commission argues four specifics that give health care a special kind of
importance
1. Wellbeing
2. Opportunity
3. Information
4. The interpersonal and social importance of health care

Well-being
- Be promoted by preventing or relieving pain, suffering and disability
- Avoiding loss of life

Opportunity
- Health care access broadens opportunity

Information
- Provides information on people's health

Social aspect
- Can be viewed as the society’s solidarity in the face of suffering and death
- Healthcare serves a role is expressing empathy and compassion to one another
Commission Argues
- The special nature of health care helps to explain why it ought to be accessible,
in a fair and equitable fashion to all
- These things are important for living a reasonably full and satisfying life
- In order for an adequate level of care to be equitable the burdens of accessing
care must not be excessive (ex. Long travel, long wait hours, or use of most
financial resources)

Commission Conclusion
- In light of the special importance of health care, the largely underserved
character of differences in health status, and the uneven distribution and
unpredictability of health care needs, society has a moral obligation to ensure
adequate care for all

Jan Narveson
- States the argument made by the commission is equivalent to “proclaim all
Americans have the right against their government…to that level of care”
- To say someone has a right is to say someone else has a duty
- Narveson raises two questions 1. What kind of right are we talking about? 2. Is
the government and its citizens through forms of taxations, truly morally
obligated to create and maintain a publicly funded form of health care that
provides adequate care to all? Narveson says no
- Thinks we do not have a right to an adequate level of health care

Narveson Negative rights

- Rights that others not do certain things to the right holder
- The corresponding duty is to refrain from some action

Narveson Positive right

- Right to provide the right holder with something in the way of a good or
service that is advantageous to the recipient
- Freedom to certain things like good or services
- The corresponding duty is to provide the help that is needed, if we are able to
do so

Moral Significance
- What we morally are allowed to compel each other to respect if compulsion
should be needed to elicit the respect in question
Narveson Arguments
- The right easily establishes a long list of negative rights
- Security of the person
- Security of property
- Recognition of transfers by consent only
- The reliability of contracts
- Narveson thinks that rational individuals would share no common interest in
satisfying the health needs of others
- we couldn’t be compelled to contribute to any of these goods or services at all

Narveson on the Commission

- Narveson believes the commissions argument in favour of a right to an
adequate level of health care is a positive right
- Narveson argues that this assumption entails that we require people to
contribute to establishing publicly funded health care and therefore this
assumption is wrong

Narveson Beliefs
- Narveson believes people can contribute to publicly funding of health
care if they choose to and should only be voluntary
- No one should be compelled
- The minimum amount of health care that people are entitled to, given a
positive right to health care is zero

Module 10 - Obligations to the poor

Peter singer
- Utilitarian - we should promote happiness and well-being to the greatest
number
- We have a strong moral obligation to fund effective charities like the
Against Malaria Foundation
 - Moral obligation to prevent bad things from happening to people
- Believes in moral obligation to alleviate suffering and death caused by
extreme poverty
- “Simple and intuitive” if it is in our power to prevent something bad from
happening then we must do it

Effective Altruism
- You should do the most good you can do
- Based on utilitarianism
- Promote happiness and wellbeing for the greatest number

Poverty
- One of the most significant social determinants of health
- Defined as having a low income where one cannot afford a certain
standard of living
Absolute poverty: compares income to the cost of meeting basic necessities,
people can’t afford basics to life (ex. Food, water, shelter)
Relative poverty: compares peoples’ standard of living within a certain
jurisdiction or geographic area

The World Bank

- Poverty line is .15 USD per person per day, anyone below is in a condition
of extreme poverty
- 648 million people globally living on less that $2.15 per day in 2019

Singer
- The principle of easy rescue
- This principle holds that “if it is in our power to prevent something bad
from happening, without thereby sacrificing anything of comparable
moral importance, we ought, morally, to do it”
- The cases of Bob’s Bugatti or the child drowning in the shallow pond lends
intuitive support for such this principle

his principle implies two things:

1. It takes no account of proximity or distance; and,

2. It makes no distinction between cases where only I could do something,
and cases where I am one among millions in the same position.
 - Singer thinks this intuitive belief holds in cases where we could
plausibly help others experiencing extreme poverty.

Premise 1: Suffering and death from lack of food, shelter and medical care are
bad

Premise 2: If it is in your power to prevent something bad from happening,

without sacrificing anything nearly as important it is wrong not to do so
(therefore this proves that students who don't have as much disposable income,
donating doesn't necessarily apply to them)

Premise 3: By donating to aid agencies, you can prevent suffering and death
from lack of food, shelter, and medical care, without sacrificing anything nearly
as important

Conclusion: therefore if you do not donate to aid agencies, you are doing
something wrong

Thought Experiment

- Hypothetical situations that get us to deeply think about what is the best
thing to do
- Singer’s shallow pond thought experiement

Conclusion to Singer Argument

Singer’s argument ultimately suggests that if we can prevent something bad

from happening, like suffering or death from lack of food, shelter, or medical
care, then we ought, morally speaking, to do it.

➢ Singer’s argument implies that we have strong moral obligations to

donate, perhaps even large sums of our income, to such charities—so long
as doing so doesn’t sacrifice anything of comparable moral value. For
example, the cost of eating takeout—even if it is really tasty!—cannot
compare to the moral value of a person’s health or their life. So, we ought
to forego these relative luxuries and donate.
➢ MUST DONATE TO CHARITIES THAT ARE EFFECTIVE
Travis Timmerman

- Believes Singer’s idea of donating significant amounts of our money to

charity was too demanding
- Timmerman grants that Premise 1 and Premise 3 in Singer’s argument are
true—that is, he assumes that they are true. His goal, then, is to argue
“that Singer has not provided sufficient justification for the truth of
Premise 2” (138). He argues that we can show that Premise 2 is false. And
if Timmerman is right, then Singer’s argument is logically unsound.
- Logical validity: An argument is logically valid if and only if it is
impossible for the premises to be true and the conclusion false, when the
premises are assumed to be true. In a logically valid argument, the logical
structure of the premises necessitates the truth of the conclusion.
- Logical soundness: An argument is logically sound if and only if it is both
logically valid and the premises of the argument are actually true.

Timmerman Argues

- Timmerman argues that Premise 2, which holds that “if it is in your power
to prevent something bad from happening, without sacrificing anything
nearly as important, it is wrong not to do so”, is false. And if he is
successful in showing this, then Singer’s argument will be unsound.
- Timmerman thinks that Premise 2 is “deceptively demanding of us as
moral agents, far too demanding to be intuitively compelling”
- Timmerman asks, “[a]ren’t we morally obligated to sacrifice our new
clothes to save the child because we are obligated to prevent something
bad from happening whenever we can do so without sacrificing anything
nearly as important? The short answer is ‘No’”

Module 11: Equipoise and Clinical Research

Module 12: Research on non-human
animals