1 Philosophy 228 Public Health Ethics Fall 2010 Goergen 108, TuTh 9:40-10:55 Richard Dees, Ph.D.

Office: Lattimore 529 Hours: Tu 11:15-12:00, Th 11:15-1:30 and by appointment Phone: 275-8110 richard.dees@rochester.edu TA: Matt Facemyer Lattimore 534 WF 1:00-2:00 and by appointment 275-4387 t.facemyer@rochester.edu

Most health care ethics focuses on the individual decisions about health care, but many ethical questions have implications for society at large. The demands that individual health decisions make on the system may create collective problems, and conversely, the needs of society may limit the freedoms that individuals think they should have. Public health ethics then, lie at the intersection of medicine, political philosophy, and public policy. This course will examine the values of health, social needs, and freedom through a systematic examination of situations in which these conflicts arise. We will examine the issues by looking at it through three levels: through theoretical readings in philosophy, through readings in the broad issues of public health, and by considering case studies. Required Texts: Norman Daniels, Just Health (Cambridge) John Stuart Mill, On Liberty (Hackett) John Rawls, A Theory of Justice (Harvard) Readings on Blackboard Optional text: Ronald Bayer, et al., eds. Public Health Ethics (Oxford). Many of the readings are found in this anthology, but for almost all of these articles, I have provided Blackboard links to the original articles. Course Requirements: Class participation is worth a significant portion of your grade. The class is based on student discussions, not on lectures. You are expected to come to class, and you are expected to come to class prepared to discuss the readings if only to ask relevant questions about them. Every other week, you will be expected to write a brief one-page reaction to the weeks reading and be prepared to send it by e-mail to each of the teachers by 9:00 p.m. on Monday. The weeks you are assigned to do a reaction paper is listed in the readings. The major assignments in this course will be done using a tutorial system. Twice during the term, I will give you a series of questions about particular texts. You will choose one question and write a 6-8 page analytical paper. You and another student will then meet with me

2 in my office to discuss and hand in your papers. Classes will be cancelled during the tutorials. I will explain the tutorial method in more detail later. For your final assignment, you will write an 8-10 page paper. This paper can be a third tutorial paper on a topic I give you, or on a subject of your own choosing. The latter option gives you the opportunity to explore an issue of particular interest to you. Before beginning such a paper, however, you must talk to me, so that I can make sure that the topic is suitable, and also so that I can help you with resources. The course grade is divided into 17 parts, apportioned as shown: First tutorial Oct 4 4 parts Second tutorial Nov 2 4 parts Final assignment Dec 10 5 parts Participation 4 parts Schedule of Readings: This schedule is tentative (especially for topics later in the course). However, any changes will be announced on Blackboard, and an up-to-date copy of the syllabus can always be found on Blackboard. All readings, except those in the required books for the class, are on Blackboard. PHE indicates pages in Public Health Ethics. Below the date for each week, you will find a number for the group of students is responsible for sending in a reaction paper. Group 1 is everyone with a last name beginning with A to J. Group 2 is K to Z. I. Introduction Sep 2 Sep 7-9 (1) Introduction Case study 1: Smoking CDC Smoking Facts Robert Levy and Rosalind Marimont, "Lies, Damned Lies, and 400,000 Smoking-Related Deaths," Regulation 21 (1998): 24-29. Robert Goodin, No Smoking: The Ethical Issues (PHE 117-26) Jacob Sullum, For Your Own Good: The Anti-Smoking Crusade and the Tyranny of Public Health (PHE 127-33) Kristin Voigt, "Smoking and Social Justice," Public Health Ethics 3 (2010): 91-106. Mark Rothstein, Rethinking the Meaning of Public Health, Journal of Law, Medicine, and Ethics 30 (2002): 144-49 (PHE 71-81) Daniel Goldberg, In Defense of a Broad Model of Public Health, Public Health Ethics 2 (2009): 70-83 James Childress, et al., Public Health Ethics: Mapping the Terrain, Journal of Law, Ethics, and Medicine 30 (2002): 170-78

II. Public goods problems Sep 14 (2) Derek Parfit, Practical Dilemmas, Reasons and Persons (Oxford: Oxford University Press, 1984), 53-66

3 Russell Hardin, The Free Rider Problem, Stanford Encyclopedia of Philosophy Dan Beauchamp, Community: The Neglected Tradition in Public Health, Hastings Center Report 15.6 (1985): 28-36 (PHE 45-56) Geoffrey Rose, Sick Individuals and Sick Populations, International Journal of Epidemiology 14 (1985): 32-38 (PHE 33-43) Sep 16-21 (1) Case study 2: Immunizations Douglas Diekema and Edgar Marcuse, Ethical Issues in the Vaccination of Children, in Primum Non Nocere Today, ed. G.R. Burgio and J.D. Lantos (Amsterdam: Elsevier, 1998), pp. 37-47 (PHE 279-88) Chris Feudtner and Edgar Marcuse, Ethics and Immunization Policy: Promoting Dialogue to Sustain Consensus, Pediatrics 107 (2001): 115864 Barbara Loe Fisher, In the Wake of Vaccines Arthur Caplan, Vaccines and Autism Robert Field and Arthur Caplan, "A Proposed Ethical Framework for Vaccine Mandates: Competing Values and the Case of HPV," Kennedy Institute of Ethics Journal 18 (2008): 111-24 Angus Dawson, Herd Protection as a Public Good: Vaccination and Our Obligations to Others, in Public Health, in Ethics, Prevention, and Public Health, ed. Angus Dawson and Marcel Verweij (Oxford: Oxford University Press, 2007), 160-78 Optional: Shots in the Dark from radio show, This American Life, 19 December 2008

III. Public health vs. individualism Sep 23 Sep 28-30 (2) John Stuart Mill, On Liberty, chs. 1, 3 (pp. 1-14, 53-72) Mill, chs. 4-5 (pp. 73-113) Gerald Dworkin, Paternalism, in Paternalism ed. Ralph Sartorius (Minneapolis: University of Minnesota Press, 1983), 19-34 Bruce Jennings, Public Health and Liberty: The Millian Paradigm, Public Health Ethics 2 (2009): 121-34 Thomas Nys, Paternalism in Public Health Care, Public Health Ethics 1 (2008): 64-72 . First tutorials (No classes) Daniel Wikler, Who Should be Blamed for Being Sick, Health Education Quarterly 14 (1987): 11-25 (PHE 89-104) Ronald Bayer and Jonathan Moreno, Health Promotion: Ethical and Social Dilemmas of Government Policy, Health Affairs 5 (1986): 72-85 (PHE 105-16)

Oct 5-7 Oct 12-14 (1)

4 Case study 3: Obesity Kelly Brownell and Thomas Frieden, Ounces of Prevention: The Public Case for Taxes on Sugared Beverages, New England Journal of Medicine 360 (2009): 1805-08 Paul Campos, et al., The Epidemiology of Overweight and Obesity: Public Health Crisis or Moral Panic?, International Journal of Epidemiology 35 (2006): 55-60 Soowon Kim and Barry Popkin, Understanding the Epidemiology of Overweight and Obesity, International Journal of Epidemiology 35 (2006) 60-67 E. Fering, Lifestyle, Responsibility, and Justice, Journal of Medical Ethics 34 (2008): 33-36 Sren Holm, Parental Responsibility and Obesity in Children, Public Health Ethics 1 (2008): 21-29 Oct 19-21 (2) Case study 4: Responding to epidemics World Health Organization, Ethical Considerations in Developing a Public Health Response to Pandemic Influenza (2007), chs. 3-4 (pp. 5-11) Gina Kolata, Swine Flu, from Flu (New York: Farrar, Straus, and Giroux, 1999), 121-50 Sheri Fink, "Worst Case: Choosing Who Survives in a Flu Epidemic," New York Times, October 24, 2009 Wendy Parmet, JS Mill and the American Law of Quarantine, Public Health Ethics 1 (2008): 210-22 Ronald Bayer and Laurence Dupuis, "Tuberculosis, Public Health, and Civil Liberties," Annual Review of Public Health 16 (1995): 307-26 Ronald Bayer and Amy Fairchild, Surveillance and Privacy, Science 290 (2000): 1898-99 (PHE 255-59) Peter A. Singer, et al., "Ethics and SARS: Lessons from Toronto," British Medical Journal 327 (2003): 1342-44 Lawrence Gostin, Ronald Bayer, and Amy Fairchild, Ethical and Legal Challenges Posed by Severe Acute Respiratory Syndrome, JAMA 290 (2003): 3229-37 (PHE 261-77) Nola Ries, The 2003 SARS Outbreak in Canada: Legal and Ethical Lessons about the Use of Quarantine, in Ethics and Epidemics (Amsterdam: Elsevier, 2006), 43-67

IV. Health Care Justice Oct 26-28 (1) John Rawls, A Theory of Justice, sections 1-4, 11-14, 22-27 (pp. 3-19, 47-73, 109-39) Robert Nozick, "Distributive Justice," Philosophy and Public Affairs 3 (1973): 45-61, 63-94 Second tutorials (No classes)

Nov 2-4

Nov 9-11 (2) Nov 16-18 (1)

Norman Daniels, Just Health, chs. 1-2 (pp. 11-78) Michael Marmot, Social Causes of Social Inequalities in Health, in Public Health, Ethics, and Equity, ed. Sudhir Anand, Fabienne Peter, and Amartya Sen (Oxford: Oxford University Press, 2004), 37-61 Daniels, chs. 3-4 (pp. 79-139) Daniels, ch. 5 (pp 140-58) Thanksgiving break (No class, Nov 25) Case study 5: Universal health care Peter Singer, "Why We Must Ration Health Care," New York Times Magazine, 15 July 2009 Atul Gawande, The Cost Conundrum, New Yorker, 1 June 2009 Ezra Klein, The Health of Nations, American Prospect, 8 May 2007 Victor Fuchs and Emmanuel Ezekiel, Health Care Reform: Why? What? When? Health Affairs 24 (2005): 1399-1414 David DeGrazia, Single Payer Meets Managed Competition, Hastings Center Report 38 no. 1 (2008): 23-33, with commentaries (optional) by Paul Menzel (34-36), Len Nichols (36-38), and Ezekiel Emmanuel (38-41) Robert Sade, Foundational Ethics of the Health Care System: The Moral and Practical Superiority of Free-Market Reforms, Journal of Medicine and Philosophy 33 (2008): 461-97 Basics of the Affordable Care Act of 2010 Case study 6: Newborn screening Mary Ann Bailey and Thomas Murray, Ethics, Evidence, and Cost in Newborn Screening, Hastings Center Report 38 no. 3 (2008): 23-31 Virginia Moyer, et al., Expanding Newborn Screening, Hastings Center Report 38 no. 3 (2008): 32-39 Niels Nijsingh, Informed Consent and the Expansion of Newborn Screening, in Ethics, Prevention, and Public Health, ed. Angus Dawson and Marcel Verweij (Oxford: Oxford University Press, 2007), 198-212 Third tutorials/Final assignment, due Dec 10 No class, Dec 9

Nov 23 Nov 30Dec 2 (2)

Dec 7

Dec 9