1. Modes of Ethical Reasoning
Confidentiality
Modes of Ethical Reasoning

2. Confidentiality
One of few modern health care ethics precepts included in Hippocratic Oath
Everyone says it is serious
No one says it is absolute

3. Why Is Confidentiality Important?
What if no bad consequences follow from revealing private information?
Most people would feel wronged even if no bad consequences
Suggests moral reasoning is more Kantian than utilitarian (respect for persons)

4. Confidentiality and Autonomy
How is violation of confidentiality a threat to personal autonomy?
Control over intimate relationships

5. Most distant
Most
intimate Me

6. Most distant
Most
intimate
Choose
freely to
disclose
personal
information Me

7. Most distant
Most
intimate Me
Choose
to withhold
personal
information

8. When to Override Confidentiality?
High risk of serious harm to identifiable person
No alternative way to avoid harm
One takes steps available to minimize harm to patient from disclosure

9. Overriding Confidentiality
To prevent harm to a third party (see previous justifications)
To prevent harm to the patient (same criteria as justifying paternalism)

10. Reporting Law: A Special Case
Law is publicly known
We have obligations to know what the law is
Therefore can argue that patient has implicitly given consent if now seeking medical care under those circumstances
How valid a justification?

11. Approaches to Ethical Reasoning
Principles
Cases
Either-or or both-and?

12. Abstract principles
Concrete specific judgments
PRINCIPLES
CASES

13. Principles
Ethical wisdom lies in a small number of concise, abstract principles
From principles can deduce what to do in a given case
Case “anecdotes” are merely illustrative of the correct application of principles

14. Cases (Casuistry)
Ethical wisdom consists of detailed, nuanced, concrete judgments about specific cases
Often uses maxims or rules but these are general organizing concepts, not infallible sources of ethical insight
Often a rule or maxim creates a line of cases

15. The “Truth” Line of Cases
Maxim: Don’t lie
Paradigm case: George W. and the cherry tree
“Line of cases”: Each new case differs just a little more from the paradigm case; as one gets farther away a wider variety of other ethical considerations compete with the maxim

16. Difficult Cases
Kant: Do you tell the truth to the homicidal lunatic who asks which way your friend went?
At intersection of two lines of cases-- “Don’t lie” and “Protect lives” maxims

17. Reasoning About Cases
Differences: how two cases which at first glance seem identical actually have features requiring different ethical analyses or actions
Analogy: how two cases which at first seem quite different actually have common features which may point to an ethical resolution

18. Abstract principles
REFLECTIVE
EQUILIBRIUM
Concrete specific judgments

19. Reflective Equilibrium
Look for best overall “fit”
Reason both from cases to principles and from principles to cases
Sometimes a specific case judgment will seem better “grounded,” other times a principle will
Be willing to revise ethical judgments based on new ideas and insights