All posts by Ella Stoede Thompson

Is ethical analysis the missing link?

Brennan’s article, written during the Clinton administration—over a decade ago—is just as relevant now as it was then. Brennan puts forward several statements, including his assessment that medical care has, at its base, ethical roots. Because of this, “ethical roots ought to inform the institutions to which they give rise and their attendant financing arrangements”. He states, in his introduction, that ethics is generally left out of debates about finance reform, and that these debates are predominantly governed by economics and politics. This is logical; it’s hard to argue with real numbers and data, which is what economics can provide.

After presenting three solutions: health care insurance reform, health care financing reform, and health care cost reform, he concludes that financing and cost reforms are necessary to remedy the situation, and that an insurance reform is simply not enough. Whether or not Brennan’s assertion about ethics being at the root of health care is true, is not as important. Ethics is inherently linked to any social industry; working for the good of people. Ethics should be considered in any debate when an outcome will affect the well being of people.

However, the problem is figuring out how to get ethics involved. Right now, Congress, a room of politicians, decides on reforms. Brennan mentions, “The plan is only now taking shape…what will eventually emerge from Congress is impossible to predict.” He is referring to the issues of health care costs and restricted access that were addressed during the Clinton administration. However, as we all are very much aware of, the health care system is still dysfunctional. “The plan”, or any plan for that matter, has not yet seemed to work.

Right now we are in the beginning stages of Obamacare, a plan significantly based on reforming insurance. However, it seems unlikely that any big “plan” is likely to work, unless the way in which plans are created and approved is reformed. It will take more then just allowing ethics to enter the “debate”, ethics must take a main role, instead of the backseat position it has been holding for a long time. If the medical system is to indeed become the social institution that it logically should be, integrating ethics—an entity to speak on behalf of people’s health—is imperative.


Investing in Lives

Healthcare, like many “public” services, is not equally available to everyone. It is true that there is some degree healthcare available to the population at large, but, due to the private sector, the quality is vastly different between groups. There are many things that factor in to the availability of quality healthcare. Things such as income, race, ethnicity, gender, age and others all play in to the healthcare a person receives. A complete list is covered in a report on health disparities published by the CDC  ( These factors ultimately come down to income and demographics. Preventive medicine deserves a larger amount of funding. If everyone does not have the same opportunity to protect their health, then should they be placed with the total responsibility of their own preventative medicine?

Education is a public service, but you can pay for better education; a higher level of learning to obtain a higher standard of living. Health care is also public, but again private healthcare is where the highest quality of care is generally found. Not because doctors are better, but because there are more resources and fewer patients. Preventative healthcare is no different in its access. There are many forms of public “prevention” that we may not even be aware of. Regulation of water, food, and air are a few things that prevent us from getting sick. For the US, these are the lowest level of prevention services provided. Beyond those things, availability of health prevention is not equal. In his argument Preventive Medicine, Brody states that “preventive medicine is most easily amenable to equal distribution”. At a basic level this is true, but to a greater extant preventative medicine is not equal.

One of the salient aspects in prevention is diet. It also happens to be one of the largest contributors to the prevalence of many chronic diseases in the US (WHO). Things such as food deserts and the limited influence and quantity of food stamps are directly related to income. When a family has a limited budget, and a bag of chips is cheaper then an apple, junk food trumps nutrition. Diet is an example of prevention that is not equal.

Like Brody mentions in Preventive Medicine, as a society we are more likely to fund life saving procedures then to invest in projects that will save lives before they are at risk. Nobody wants to pay you to keep them from getting sick. However, the cost of prevention is much less. Vaccines are a perfect example of how a small amount of money can save more lives if it is invested before those lives need to be saved.

With this information—of the cost benefits of acting early on health prevention and the disparity that currently exists in the US—can we raise the level of “basic” preventive medicine? Is it ethical that some people have the capacity to “protect” their own health through diet and other means, and others fall short? Why shouldn’t there be a larger public investment in preventative medicine, so that it may influence a larger population, ultimately saving money down the road?


WHO website

CDC Health Disparities & Inequalities Report (CHDIR)—Morbidity and Mortality Weekly Report (MMWR)


Book Title: Bioethics: Readings and Cases. 298-301. Prentice-Hall.1987

ISBN: 0130765228

Fear of the Law

The Canterbury v. Spence case brings our attention to the ethical issues of risk disclosure of a medical procedure. This type of case involves and compares the importance of several pillars of ethics: autonomy, benevolence and malevolence. There seems to be a question that is very difficult to answer, and may differ on a case-to-case basis: Does, “every human being of adult years and sound mind has a right to determine what shall be done with his own body…” (an issue of autonomy) trump a doctor acting in the patient’s best interest and avoiding harm to the patient (benevolence/malevolence)? ( It’s convenient to believe that the legal system keeps people on a moral path and helps people make decisions that are ethically sound and in the best interest of society as a whole. But in some cases, fear of the law may cause more issues than it does good.

Risk of a procedure is not the only type of information that doctors potentially keep from their patients. There is also the issue of disclosing errors that may have occurred during the process of a patient’s care. According to an article in Ghana Medical Journal ( doctors often do not tell patients or their families when an error has occurred, whether it be in surgery or anything else related to the patient’s health care. Instead, the doctors and institutions tend to try and cover up these events to avoid legal issues. In this case, the doctors are putting their own well being above that of their patients. According to the report, healthcare errors lead to more deaths than motor vehicle accidents, breast cancer or AIDS in the US. (

Putting your life, or the life of a loved one in the hands of a human, capable of error, is an act of immense trust. The article refers to the doctor-patient relationship as fiduciary; “one who owes to another the duties of good faith, trust, confidence and candour”. This is trusting the doctor to act in best interest of the patient. However, can a doctor do that if he is worried about the consequences of an error? If he puts his own well being before that of the patient’s?

In class, we have talked about the importance of intention in ethics. When it comes to health care and medicine, if someone’s life is at stake, people tend to care less about intention and more about the outcome. If an error results in a patient’s death, the family cares little about the doctor’s intention to do good, the focus is on the error that resulted in death. This is the responsibility and punishment that the doctor must shoulder as a casualty of his daily work.

Here we have two different types of disclosure: risk disclosure before a procedure, and disclosure of any errors after a procedure. For the first, the law helps to encourage doctors to share all possible complications with the patient, to avoid lawsuits should anything go wrong. For the second, the threat of the law dissuades doctors from disclosing human error events that may have occurred. This would lead us to the assumption that doctors’ morals are rooted in fear of the law rather then intrinsic human nature.

However, this is not always the case. Like in the Canterbury v. Spence case, doctors sometimes choose to not share some information that they believe may do more harm then good. They take the risk of the potential lawsuit in their effort to do what they believe is best for the patient. In this case, the doctor is putting the patient’s well being above his own. So which is more important, the patient’s autonomy or the doctor’s duty to do what he feels is best for the patient?



Edwin AK. Non-disclosure of medical errors an egregious violation of ethical principles. Ghana Med J. 2009;43(1):34–9. [PMC free article] [PubMed

Informed Consent: Opinion Canterbury v Spence Physicians’ obligations and patients’ rights.