Bioethics, Technology & Law
Vrije Universiteit Amsterdam
Period 1, year 1
,Week 1 - Changing human nature? The bioethical
triangle
Literature week 1
M. J. Roberts & M. R. Reich, Ethical Analysis in Public Health (2002)
The bioethical triangle
Public-health decisions often involve conflicts between different ethical values. Concepts such as efficiency, human
rights, cultural respect, equality, and individual choice may all seem important, but they can point toward different
policies. The main problem is therefore not simply identifying ethical values, but deciding what those values mean
and how they should be balanced when they conflict.
There are three main ethical frameworks:
Framework Main focus Central question
Utilitarianism Consequences and overall well- Which policy produces the greatest
being overall benefit?
Liberalism Individual rights, freedoms, and Does the policy respect people's
opportunities rights and give them fair
opportunities?
Communitarianism Community, shared values, and What kind of society/community
social order should we promote?
Utilitarianism: focus on the outcomes
- Utilitarianism judges a policy mainly according to its consequences.
- The aim is to maximize the total amount of well-being across individuals. A public-health intervention can
therefore be justified when its overall benefits outweigh its harms.
- Key idea: what produces the best overall consequences?
o Example: a vaccination programme might be supported because it prevents large numbers of
illnesses and deaths, even if participating creates a small burden for individuals.
Liberalism: focus on rights and opportunities
-Liberalism focuses more on individual rights, freedom, and opportunities than on maximizing the final
outcome.
- Key idea: are people's rights, freedoms, and opportunities protected?
o Example: banning smoking inside public buildings can be justified because second-hand smoke
affects other people's health. But completely banning adults from smoking privately could be
considered an excessive restriction of individual liberty.
Communitarianism: focus on the community
- Communitarianism focuses on the values and well-being of the community, rather than beginning with
isolated individuals.
- Ethical decisions can therefore depend partly on the traditions, relationships, responsibilities, and shared
values of a particular community.
- Individual choices should be considered in relation to the values, responsibilities, and well-being of the
community.
- Key idea: what kind of community or society should we create and maintain?
o Example: strongly encourage or sometimes require vaccination because protecting public health is
understood as a shared social responsibility.
,
, Utilitarianism in public health
Public-health policymaking is often based on an analysis of consequences. The right choice is viewed as the one that
produces the most gain, for example, the largest reduction in the burden of disease. If policy is to be judged by its
effect on the sum of individual levels of wellbeing, we need to measure and add up these magnitudes. In modern
times, utilitarians have divided into two camps.
- Subjective utilitarianism: individuals determine the value of a health benefit themselves.
o ‘’How much would you be willing to pay for a treatment that removes your chronic back pain?”
o If people are willing to pay a lot, this indicates that they value the health benefit highly.
o Cost-benefit analysis
o But, willingness to pay depends on someone's ability to pay. A wealthy person's preference could
therefore count more strongly than a poor person's preference.
- Objective utilitarianism: using standardized measures determined by experts.
o Cost-effectiveness analysis
o Unlike cost-benefit analysis, the benefit does not have to be converted into money.
o QALY (Quality-Adjusted Life Year): combines additional years of life with their quality.
o DALY (Disability-Adjusted Life Year): measures healthy years of life lost because of disability, illness, or
premature death.
Utilitarian reasoning is extremely useful in public health, but it creates several important ethical problems:
- Measuring well-being is difficult: there may be no universal, objective way of measuring health or well-being.
- Subjective preferences can be biased or unequal: people do not necessarily evaluate risks consistently and
willingness to pay reflects wealth as well as preference.
- Maximizing total welfare can conflict with fairness and individual rights: if the only goal is maximize total
well-being, then theoretically, harming a small number of people could be justified if doing so creates
sufficiently large benefits for everyone else.
The authors do not totally reject utilitarianism. Consequences are central to public health because policymakers
need to consider consequences. But consequences cannot necessarily be the only consideration.
Ethics of care: argues that traditional ethical theories often overlook something fundamental about human life:
people live in relationships of care, dependence, and responsibility. It is a form of consequentialism because it cares
about outcomes, but it challenges the way utilitarianism thinks about those outcomes.
- Utilitarianism: Everyone's well-being should count equally. You should not give greater moral importance to
your mother, child, friend, or neighbour simply because you have a relationship with them.
- Ethics of care: this does not reflect how real caring relationships work. You cannot and should not care for
every human being in exactly the same way.
o Society should support both vulnerable people and those who care for them.
Vrije Universiteit Amsterdam
Period 1, year 1
,Week 1 - Changing human nature? The bioethical
triangle
Literature week 1
M. J. Roberts & M. R. Reich, Ethical Analysis in Public Health (2002)
The bioethical triangle
Public-health decisions often involve conflicts between different ethical values. Concepts such as efficiency, human
rights, cultural respect, equality, and individual choice may all seem important, but they can point toward different
policies. The main problem is therefore not simply identifying ethical values, but deciding what those values mean
and how they should be balanced when they conflict.
There are three main ethical frameworks:
Framework Main focus Central question
Utilitarianism Consequences and overall well- Which policy produces the greatest
being overall benefit?
Liberalism Individual rights, freedoms, and Does the policy respect people's
opportunities rights and give them fair
opportunities?
Communitarianism Community, shared values, and What kind of society/community
social order should we promote?
Utilitarianism: focus on the outcomes
- Utilitarianism judges a policy mainly according to its consequences.
- The aim is to maximize the total amount of well-being across individuals. A public-health intervention can
therefore be justified when its overall benefits outweigh its harms.
- Key idea: what produces the best overall consequences?
o Example: a vaccination programme might be supported because it prevents large numbers of
illnesses and deaths, even if participating creates a small burden for individuals.
Liberalism: focus on rights and opportunities
-Liberalism focuses more on individual rights, freedom, and opportunities than on maximizing the final
outcome.
- Key idea: are people's rights, freedoms, and opportunities protected?
o Example: banning smoking inside public buildings can be justified because second-hand smoke
affects other people's health. But completely banning adults from smoking privately could be
considered an excessive restriction of individual liberty.
Communitarianism: focus on the community
- Communitarianism focuses on the values and well-being of the community, rather than beginning with
isolated individuals.
- Ethical decisions can therefore depend partly on the traditions, relationships, responsibilities, and shared
values of a particular community.
- Individual choices should be considered in relation to the values, responsibilities, and well-being of the
community.
- Key idea: what kind of community or society should we create and maintain?
o Example: strongly encourage or sometimes require vaccination because protecting public health is
understood as a shared social responsibility.
,
, Utilitarianism in public health
Public-health policymaking is often based on an analysis of consequences. The right choice is viewed as the one that
produces the most gain, for example, the largest reduction in the burden of disease. If policy is to be judged by its
effect on the sum of individual levels of wellbeing, we need to measure and add up these magnitudes. In modern
times, utilitarians have divided into two camps.
- Subjective utilitarianism: individuals determine the value of a health benefit themselves.
o ‘’How much would you be willing to pay for a treatment that removes your chronic back pain?”
o If people are willing to pay a lot, this indicates that they value the health benefit highly.
o Cost-benefit analysis
o But, willingness to pay depends on someone's ability to pay. A wealthy person's preference could
therefore count more strongly than a poor person's preference.
- Objective utilitarianism: using standardized measures determined by experts.
o Cost-effectiveness analysis
o Unlike cost-benefit analysis, the benefit does not have to be converted into money.
o QALY (Quality-Adjusted Life Year): combines additional years of life with their quality.
o DALY (Disability-Adjusted Life Year): measures healthy years of life lost because of disability, illness, or
premature death.
Utilitarian reasoning is extremely useful in public health, but it creates several important ethical problems:
- Measuring well-being is difficult: there may be no universal, objective way of measuring health or well-being.
- Subjective preferences can be biased or unequal: people do not necessarily evaluate risks consistently and
willingness to pay reflects wealth as well as preference.
- Maximizing total welfare can conflict with fairness and individual rights: if the only goal is maximize total
well-being, then theoretically, harming a small number of people could be justified if doing so creates
sufficiently large benefits for everyone else.
The authors do not totally reject utilitarianism. Consequences are central to public health because policymakers
need to consider consequences. But consequences cannot necessarily be the only consideration.
Ethics of care: argues that traditional ethical theories often overlook something fundamental about human life:
people live in relationships of care, dependence, and responsibility. It is a form of consequentialism because it cares
about outcomes, but it challenges the way utilitarianism thinks about those outcomes.
- Utilitarianism: Everyone's well-being should count equally. You should not give greater moral importance to
your mother, child, friend, or neighbour simply because you have a relationship with them.
- Ethics of care: this does not reflect how real caring relationships work. You cannot and should not care for
every human being in exactly the same way.
o Society should support both vulnerable people and those who care for them.
