The AIDS and Needles Case

Question: Using the Utilitarian, Kantian, Rights, and Distributive Justice approaches to ethical decision-making, provide an analysis of the initial ethical dilemma you identified in the case. (NB: Use each of the theories separately in your analysis). { the ethical dilemma is to change the design of the syringe or not}. The case study is given below:

The AIDS and Needles Case

 

 

Becton Dickinson, one of the largest manufacturers of medical supplies, dominates the US market in disposable syringes and needles. In 2005, a nurse, Maryann Rockwood (a fictional name), used a Becton Dickinson 5cc syringe and needle to draw blood from a patient known to be infected with HIV (Human immunodeficiency virus). Ms. Rockwood worked in a clinic that served AIDS patients, and she drew blood from these patients several times a day. After drawing the blood on this particular day, she transferred the HIV-contaminated blood to a sterile test tube by sticking the needle through the rubber stopper of the test tube, which she was holding with her other hand. She accidentally pricked her finger with the contaminated needle. She is now HIV positive.

 

 

A few years earlier, in 2000, Becton Dickinson had acquired exclusive rights to a patent for a new syringe that had a moveable protective sleeve around it. The plastic tube around the syringe could slide down to safely cover the needle. The Becton Dickinson 5cc syringe used by Maryann Rockwood in 2005, however, did not yet have such a protective guard built into it. The AIDS epidemic has posed peculiarly acute dilemmas for health workers, including doctors and nurses. Doctors performing surgery on AIDS patients can easily prick their fingers with a scalpel, needle, sharp instrument, or even bone fragment and can become infected with the virus. The greatest risk is to nurses, who, after routinely removing an intravenous system, drawing blood, or delivering an injection to an AIDS patient, can easily stick themselves with the needle they were using. Needlestick injuries occur frequently in large hospitals and account for about 80 percent of reported occupational exposures to HIV among health care workers. It was conservatively estimated in 2005 that about 64 health care workers were then being infected with HIV each year as a result of needlestick injuries.

 

 

Although the fear of HIV had heightened concerns over needlestick injuries, HIV was not the only risk posed by needlestick injuries. Hepatitis B can also be contracted through an accidental needlestick. In 2000, the Centre for Disease Control (CDC) estimated, on the basis of hospital reports, that each year at least 12,000 health care workers are exposed to blood contaminated with the Hepatitis B virus, and of these 250 die as a consequence. Due to underreporting, however, the actual numbers may be higher. In addition to Hepatitis B, needlestick injuries can also transmit numerous other viral, bacterial, fungal, and parasitic infections, as well as toxic drugs or other agents that are delivered through a syringe and needle. The total statistics on needlestick injuries in 2005 are disturbing, although the exact incidence of contamination is unclear. It was estimated that each year, in the United States alone, between 800,000 and 1 million needlestick injuries occurred in hospitals – of these, between 60,000 and 300,000 resulted in Hepatitis B infection. By one estimate, the risk of contracting HIV from a known contaminated needle could be as high as 1 in 1000, and the risk of contracting Hepatitis B, a serious and often life-threatening condition, could be as high as 1 in 6. These estimates would imply that as many as 600 to 1000 health care workers were at risk of contracting HIV and as many as 100,000 were at risk of contracting Hepatitis B.

 

 

Several agencies stepped in to set guidelines for nurses, including the American Nursing Association, the CDC, the Environmental Protection Agency (EPA), and the Food and Drug Administration (FAD), who all developed such guidelines. The most comprehensive guidelines were issued by the Occupational Safety and Health Administration (OSHA), who on December 6, 2001, required hospitals and other employers of health workers to (a) make sharps containers (safe needle containers) accessible to workers, (b) prohibit the practice of recapping needles by holding the cap in one hand and inserting the needle with the other, and (c) provide information and training on needlestick prevention to employees.

 

 

The usefulness of these guidelines was controversial. Nurses work in high-stress emergency situations requiring quick action, and they are often pressed for time both because of the large number of patients they must care for and the highly variable needs and demands of these patients. In such workplace environments, it is difficult to adhere to the guidelines recommended by the agencies. For example, a high-risk source of needle sticks is the technique of replacing the cap on a needle (after it has been used) by holding the cap in one hand and inserting the needle into the cap with the other hand. OSHA guidelines specifically warned against this two-handed technique of recapping and instead required that the cap be placed on a stable surface and the nurse use a one-handed spearing technique to replace the cap. (Note that recapping the needles in this more time consuming way presented no risk of needlestick injury to the user). As noted above however, nurses are often pressed for time (and are keenly aware of the added danger of walking around with an uncapped needles) and tend to take the ‘two-handed recapping shortcut’ when no suitable surface is readily available for the safer one-handed capping technique. This fact is known to Hospital administrators, who regularly warn against such practices, and offer ongoing training and retraining opportunities to their nursing staff.

 

 

Several analysts suggested that the peculiar features of the nurse’s work environment made it unlikely that needlesticks would be prevented through mere guidelines alone: The problem was not the worker, but the design of the needle and syringe. Experts on needlestick injuries argued that, rather than trying to teach health care workers to use a hazardous device safely, the focus should be on the hazardous product design and that a whole new array of devices in which safety is an integral part of the design was required. Regulators also urged manufacturers to provide the health care worker with devices in which safety was built into the design.

 

 

The risks of contracting life-threatening diseases by the use of needles and syringes in health care settings had been well documented since the early 1980s. Well over half of all the needles and syringes used by U.S. health care workers since 1980 were being manufactured by Becton Dickinson. Despite the emerging crisis, however, Becton Dickinson decided not to modify its syringes, although it did include in each box of needled syringes an insert warning of the danger of needlesticks and of the dangers of two-handed recapping. On December 23, 2000, the U.S. Patent office issued patent number 4,631,057 to Charles B. Mitchell for a syringe with a tube surrounding the body of the syringe that could be pulled down to cover and protect the needle on the syringe. At the time, at least four other patents for needle-shielding devices existed. As Mitchell noted in his patent application, those devices all suffered from serious drawbacks. One of them would not lock the protective cover over the exposed needle, one was extremely complex, another was much longer than a standard syringe and difficult to use, and a fourth was designed primarily for use on animals.

 

 

It was Mitchell’s assessment that his invention was the only effective, easily usable, and easily manufactured device capable of protecting users from needlesticks, particularly in emergency periods or other times of high stress. Unlike other syringe designs, Mitchell’s was shaped and sized like a standard syringe so nurses already familiar with standard syringe design would have no difficulty adapting to it. Shortly after Mitchell patented his syringe, Becton Dickinson purchased from him an exclusive license to manufacture it. A few months later, Becton Dickinson began field tests of early models of the syringe using a 3cc model. Nurses and hospital personnel were enthusiastic when shown the product. However, they warned that if the company priced the product too high, hospitals, with pressures on their budgets rising, could not buy the safety syringes. With concerns about HIV rising fast, the company decided to market the product.

 

 

In 2001, with the field tests completed, Becton Dickinson had to decide which syringes would be marketed with the protective sleeves. Sleeves could be put on all of the major syringe sizes, including 1cc, 3cc, 5cc, and 10cc syringes. However, the company decided to market only a 3cc version of the protective sleeve. The 3cc syringes account for about half of all syringes used, although the larger sizes-5cc and 10cc syringes-are preferred by nurses when drawing blood. This 3cc syringe was marketed in 2002 under the trademarked name Safety-Lok Syringe. It was promoted as a device that “virtually eliminates needlesticks.” The 3cc safety syringe with the protective sleeve was sold in 2001 to hospitals and doctors’ offices for between 50 and 75 cents. By 2003, the company had dropped the price to 26 cents per unit. At the time, a regular syringe without any protective device was priced at 8 cents per unit and cost 4 cents to make. Information about the cost of manufacturing the new safety syringe is unavailable but is estimated at between 13 and 20 cents each. The difference between the price of a standard syringe and the price of the safety syringe was an obstacle for customers. To switch to the new safety syringe would increase the hospital’s costs for 3cc syringes by a factor of three. An equally important impediment to adoption was the fact that the syringe was available in only one 3cc size, and it was perceived to be of limited application. Hospitals are reluctant to adopt and adapt to a product that is not available for the whole range of applications the hospital must confront. In particular, hospitals often needed the larger 5cc and 10cc sizes to draw blood, and Becton Dickinson had not made these available with a sleeve.

 

 

For 5 years, Becton Dickinson manufactured only 3cc safety syringes. During that period, Becton Dickinson did not license its new safety syringe technology to another manufacturer that might have produced a full range of syringe sizes. Most hospitals and clinics, including the medical facility where Maryann Rockwood worked at drawing blood from many patients with Hepatitis B or HIV, did not stock the Becton Dickinson safety syringe. Most nurses in the United States continued to use unprotected syringes. Maryann Rockwood sued Becton Dickinson, alleging that, because it alone had an exclusive right to Mitchell’s patented design, the company had a duty to provide the safety syringe in all its sizes, and that by withholding other sizes from the market it had contributed to her injury. The case was settled out of court.

EXAMPLE: Case Facts

Test cricket is the oldest and most prestigious form of cricket (Tippet 2016). The matches are played between teams with “Test status” who represent their nation. A test match can go for a maximum of five days and includes two breaks for lunch and tea on each day (Tippet 2016). The schedule of all matches is determined by the International Cricket Council (ICC), the global governing body of cricket. The ICC is also responsible for monitoring the rules. ICC deals with the code of conduct for cricket and takes action against corruption and match fixing (Anwar 2017).

The national governing body for cricket in Australia is Cricket Australia (CA) (Cricket Australia 2019c). CA sets and manages the playing conditions that apply to international and interstate cricket in Australia (Cricket Australia 2019d). If a breach of the code of conduct takes place during a match, CA investigates the incident. CA awards national contracts to cricket players that form the Australia national cricket team (ANCT) (Cricket Australia 2019a) and pays them accordingly (TSM Sportz 2016). CA is sponsored by a variety of commercial partners (Cricket Australia 2019b).

 

 

In March 2018 the ANCT was scheduled to play four test matches against the South Africa national cricket team (SANCT) in South Africa. The third test match took place in Cape Town, South Africa from March 22-26 (Premium Sport Tours 2019). At that time Steve Smith was the captain of the ANCT and David Warner was the vice-captain (Ferris 2018), both were further contracted to Indian cricket teams as overseas players (Gollapudi 2015; Cricket Australia 2018b). One of the junior players in the team was Cameron Bancroft, who was further contracted to a British cricket team as an overseas player (ITV News 2017).

 

Ball-tampering in cricket refers to manipulating the ball to change its condition by polishing or roughing up one side of the ball (Mangaldas 2018). If this is done with a foreign, not approved object, it counts as cheating and is illegal under the laws of cricket (Lords 2019) and sanctioned according to the ICC Code of Conduct (ICC 2019). The reason for manipulating a ball is mostly because it isn’t swinging.

Swinging (swing bowling) means changing the direction of the ball in the air without the ball touching the ground (Ashish 2015). Changing the condition of the ball results in the ball being forced against its natural swing path by creating high air turbulence around the rough side (Huges 2018). This makes the delivery more difficult for the batsman to receive (Mangaldas 2018) and bowlers gain an advantage.

 

 

On 24 March 2018, the third day of the third test match, at the lunch break, South Africa was leading by over 100 runs, making the situation a crucial moment in the match for Australia (AssociatedPress 2018). Since 2009, the performance of Australia had been unremarkable compared to the previous 8 years, contributing to the pressure the team was under (Singh 2016). During this lunch break, in the change room, David Warner developed the plan to alter the condition of the ball artificially with sandpaper to gain an advantage over the South Africa national cricket team. He then asked Cameron Bancroft to carry out this plan after the lunch break and demonstrated how to do it. Steve Smith had knowledge of this plan but didn’t want to know anything about it (Cricket Australia 2018a; SBS News 2018).

 

 

 

 

 

 

Ethical Analysis

 

 

Utilitarianism 

Affected parties:

  • Cameron Bancroft
  • Steve Smith
  • David Warner
  • Australia national cricket team
  • South Africa national cricket team
  • Cricket Australia
  • International Cricket Council
  • Cricket fans
  • Relatives of Steve Smith, David Warner and Cameron Bancroft
  • Sponsors of Australia national cricket team

 

 

Reasonably foreseeable consequences for following the vice-president’s instructions to tamper with the ball:

  • Cameron Bancroft will illegally alter the state of the ball. He will be caught breaking the laws of cricket. He will be charged with ball tampering and will be sanctioned. His reputation will be seriously damaged, and he will lose his contract as an overseas player.
  • Steve Smith will be found out as having had knowledge of the ball-tampering plan, will be charged with a breach of the CA Code of Conduct and will be sanctioned. He will lose his position as captain, his contract as an overseas player and his reputation will be seriously damaged.
  • David Warner will be found out as having developed the plan of tampering with the ball. He will be charged with a breach of the CA Code of Conduct and will be sanctioned. He will lose his position as vice-captain, his contract as an overseas player and his reputation will be seriously damaged.
  • The performance and team culture of the ANCT will be negatively affected. Their reputation as a team will be tarnished as the action will fall back on the whole team.
  • For the batsmen of the SANCT it will be more difficult to score against a ball that has been tampered with.
  • CA will have to investigate the incident. The incident will have a negative effect on Australian Cricket, which will affect CA as an organization. They will lose sponsors due to bad publicity and lose sponsorship fees.
  • The ICC will have to look into the incident and take measures by increasing the sanctions to try to prevent similar future incidents.
  • Cricket fans will be negatively affected emotionally because they identify with their cricket team and don’t want to see unfair play.
  • The relatives of Steve Smith, David Warner and Cameron Bancroft will be put under high emotional strain due to the bad publicity the cricketers will be exposed to.
  • Sponsors of the ANCT will terminate their partnerships with CA to prevent negative PR and lose the benefits of their sponsorships.

 

 

Reasonably foreseeable consequences for not following the vice-president’s instructions to tamper with the ball:

  • David Warner will take Cameron Bancroft’s refusal as an offence. He will use his influence to have him removed from the team selection.
  • Cameron Bancroft will be removed from the team selection process. He will suffer financial loss and loss of reputation.
  • The relatives of Cameron Bancroft will be put under emotional strain due to the social implications of his changed professional status.
  • The ANCT will have difficulties scoring against the SANCT and lose the match. They will experience continued negative media commentary in relation to their ongoing poor performance.

 

 

The utilitarianism analysis concludes that the ethical dilemma alternative that produces the greatest good for the greatest number of people is “Not to follow the vice-captain’s instructions to tamper with the ball”. The consequences of following the instructions of the vice-captain by far outweigh the consequences of not following the

instructions. The number of people that would be negatively affected by the consequences of the decision to illegally tamper with the ball is significantly higher than the number of people that would be negatively affected if deciding to not tamper with the ball.

 

 

Kantianism 

Cameron Bancroft owes his primary duty in this case to his employer: Cricket Australia. Cricket Australia has a negative Right to commutative justice which enables them to engage in commerce without deception or fraud and the decision-maker is obliged to not deceive, coerce or manipulate them.

 

 

The maxims that are derived from this duty are therefore:

 

 

“To always respect commutative justice”

or

“To never respect commutative justice”

 

 

Application of the Categorical Imperative:

 

 

“To always respect commutative justice”

 

 

1. Is it universalizable? -> YES

The outcome will be that all contracts will always be respected and there will be no deception, coercion and manipulation. This outcome is self-perpetuating.

 

 

2. Does it respect rational beings? -> YES

The decision-maker’s intent is to respect Cricket Australia’s negative Right to commutative justice at the expense of his own position in the Australia national cricket team. This intent is selfless.

 

 

 

 

3. Does it respect the Autonomy of others? -> YES

The decision-maker’s intent is to not avid the breach of contract with Cricket Australia. This is respectful of their autonomy.

 

 

This maxim passes the three categorical imperative tests and is therefore ethical.

 

 

“To never respect commutative justice”

 

 

1. Is it universalizable? -> NO

The outcome will be that all contracts will never be respected and there will always be deception, coercion and manipulation. This outcome is self-defeating.

 

 

2. Does it respect rational beings? -> NO

The decision-maker’s intent is to protect his position in the Australia national cricket team at the expense of Cricket Australia’s negative Right to commutative justice. This intent is selfish.

 

 

3. Does it respect the Autonomy of others? -> NO

The decision-maker’s intent is to breach the employment contract agreement that they have with Cricket Australia. This is disrespectful of their autonomy.

 

 

This maxim fails the three categorical imperative tests and is therefore unethical.

 

 

The maxim “To always respect commutative justice” is derived from the decision “To not follow the vice-captain’s instructions to tamper with the ball” and therefore would be the right ethical decision from a Kantian perspective.

 

 

Ethical Rights 

The Rights at play in this case are:

 

 

  • Cameron Bancroft’s negative Right to make a sporting decision, which obligates others to not prevent him from doing so
  • Steve Smith’s negative Right to autonomy, which obligates others to not deceive, coerce or manipulate him. Smith gave up this negative Right when “he didn’t want to know what was going on”
  • Australia national cricket team’s negative Right to commutative justice, which obligates others to not deceive, coerce or manipulate them
  • Cricket Australia’s negative Right to commutative justice, which obligates others to not deceive, coerce or manipulate them
  • International Cricket Council’s negative Right to commutative justice, which obligates others to not deceive, coerce or manipulate them
  • South Africa national cricket team’s negative Right to commutative justice, which obligates others to not deceive, coerce or manipulate them

 

 

The clashing Rights in this case are: Cameron Bancroft’s negative Right to make a sporting decision and Cricket Australia’s negative Right to commutative justice as this is the first clash of rights at the point of the ethical dilemma.

 

 

Cricket Australia’s negative Right to commutative justice prevails because it is the most basic right in the Hierarchy of Rights. If there was no negative Right to commutative justice, the negative Right to make a sporting decision would not exist.

 

 

Therefore, the Rights analysis concludes that the most ethical decision, that preserves Cricket Australia’s negative Right to commutative justice, is “To not follow the vice-captain’s instructions to tamper with the ball”. 

 

 

Distributive Justice

When going behind the “Veil of Ignorance” the worst-off parties at the point of the ethical dilemma are:

 

 

  • Cameron Bancroft, because he is facing an ethical dilemma
  • Cricket Australia, because their negative Right to commutative justice is being violated
  • South Africa national cricket team, because their negative Right to autonomy is being violated
  • Australia national cricket team members, because their negative Right to autonomy justice is being violated
  • International Cricket Council, because their negative Right to commutative justice is being violated

 

 

Cricket Australia is the most worst-off at the point of the ethical dilemma because their negative Right to commutative justice is being violated due to Cameron Bancroft seriously considering defrauding them. Although other parties’ negative Right to commutative justice is also being violated for the same reason, the first clash of Rights at the point of the ethical dilemma is the one between Cameron Bancroft and Cricket Australia, so Cricket Australia’s negative Right to commutative justice prevails over the other parties Rights. Cameron Bancroft must therefore choose the outcome that best serves Cricket Australia.

 

 

The outcomes of the two ethical dilemma decisions are:

 

 

  • “To follow the vice-captain’s instructions to tamper with the ball” would have the outcome that all violations of Cricket Australia’s negative Right to commutative justice would perpetuate.
  • “To not follow the vice-captain’s instructions to tamper with the ball” would have the outcome that the violation of Cricket Australia’s negative Right to commutative justice would cease.

 

 

As “To not follow the vice-captain’s instructions to tamper with the ball” is the outcome which improves the position of the worst-off, it therefore is the right ethical decision according to distributive justice.

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