A Philosopher's Blog

Right-to-Try

Posted in Business, Ethics, Law, Medicine/Health, Philosophy by Michael LaBossiere on August 7, 2017

There has been a surge of support for right-to-try bills and many states have passed these into law. Congress, eager to do something politically easy and popular, has also jumped on this bandwagon.

Briefly put, the right-to-try laws give terminally ill patients the right to try experimental treatments that have completed Phase 1 testing but have yet to be approved by the FDA. Phase 1 testing involves assessing the immediate toxicity of the treatment. This does not include testing its efficacy or its longer-term safety. Crudely put, passing Phase 1 just means that the treatment does not immediately kill or significantly harm patients.

On the face of it, the right-to-try is something that no sensible person would oppose. After all, the gist of this right is that people who have “nothing to lose” are given the right to try treatments that might help them. The bills that propose to codify the right into law make use of the rhetorical narrative that the right-to-try laws would give desperate patients the freedom to seek medical treatment that might save them and this would be done by getting the FDA and the state out of their way. This is a powerful rhetorical narrative since it appeals to compassion, freedom and a dislike of the government. As such, it is not surprising that few people dare argue against such proposals. However, the matter does deserve proper critical consideration.

One interesting way to look at the matter is to consider an alternative reality in which the narrative of these laws was spun with a different rhetorical charge—negative rather than positive. Imagine, for a moment, if the rhetorical engines had cranked out a tale of how the bills would strip away the protection of the desperate and dying to allow predatory companies to use them as Guinea pigs for their untested treatments. If that narrative had been sold, people would be howling against such proposals rather than lovingly embracing them. Rhetorical narratives, be they positive or negative, are logically inert. As such, they are irrelevant to the merits of the right-to-try proposals. How people feel about the proposals is also logically irrelevant as well. What is wanted is a cool examination of the matter.

On the positive side, the right-to-try does offer people the chance to try treatments that might help them. It is, obviously enough, hard to argue that people do not have a right to take such risks when they are terminally ill. That said, there are still some points that need to be addressed.

One important point is that there is already a well-established mechanism in place to allow patients access to experimental treatments. The FDA already has system of expanded access that apparently approves the overwhelming majority of requests. Somewhat ironically, when people argue for the right-to-try by using examples of people successfully treated by experimental methods, they are showing that the existing system already allows people access to such treatments. This raises the question about why the laws are needed and what it changes.

The main change in such laws tends to be to reduce the role of the FDA in the process. Without such laws, requests to use such experimental methods typically have to go through the FDA (which seems to approve most requests).  If the FDA was denying people treatment that might help them, then such laws would seem to be justified. However, the FDA does not seem to be the problem here—they generally do not roadblock the use of experimental methods for people who are terminally ill. This leads to the question of what factors are limiting patient access.

As would be expected, the main limiting factors are those that impact almost all treatment access: costs and availability. While the proposed bills grant the negative right to choose experimental methods, they do not grant the positive right to be provided with those methods. A negative right is a liberty—one is free to act upon it but is not provided with the means to do so. The means must be acquired by the person. A positive right is an entitlement—the person is free to act and is provided with the means of doing so. In general, the right-to-try proposals do little or nothing to ensure that such treatments are provided. For example, public money is not allocated to pay for such treatments. As such, the right-to-try is much like the right-to-healthcare for most people: you are free to get it provided you can get it yourself. Since the FDA generally does not roadblock access to experimental treatments, the bills and laws would seem to do little or nothing new to benefit patients. That said, the general idea of right-to-try seems reasonable—and is already practiced. While few are willing to bring them up in public discussions, there are some negative aspects to the right-to-try. I will turn to some of those now.

One obvious concern is that terminally ill patients do have something to lose. Experimental treatments could kill them significantly earlier than their terminal condition or they could cause suffering that makes their remaining time even worse. As such, it does make sense to have some limit on the freedom to try. After all, it is the job of the FDA and medical professionals to protect patients from such harms—even if the patients want to roll the dice.

This concern can be addressed by appealing to freedom of choice—provided that the patients are able to provide informed consent and have an honest assessment of the treatment. This does create something of a problem: since little is known about the treatment, the patient cannot be well informed about the risks and benefits. But, as I have argued in many other posts, I accept that people have a right to make such choices, even if these choices are self-damaging. I apply this principle consistently, so I accept that it grants the right-to-try, the right to same-sex marriage, the right to eat poorly, the right to use drugs, and so on.

The usual counters to such arguments from freedom involve arguments about how people must be protected from themselves, arguments that such freedoms are “just wrong” or arguments about how such freedoms harm others. The idea is that moral or practical considerations override the freedom of the individual. This is a reasonable counter and a strong case can be made against allowing people the right to engage in a freedom that could harm or kill them. However, my position on such freedoms requires me to accept that a person has the right-to-try, even if it is a bad idea. That said, others have an equally valid right to try to convince them otherwise and the FDA and medical professionals have an obligation to protect people, even from themselves.

 

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GoFundMe(dical Expenses)

Posted in Ethics, Medicine/Health, Philosophy by Michael LaBossiere on July 3, 2017

While the United States does offer some of the best health care in the world, it also offers the most expensive care. What it does not offer is the sort of medical coverage for the citizens that other Western countries provide. As such, many citizens are on their own when it comes to paying for this expensive care. As of this writing, Trumpcare has not passed, but it seems likely that the final version will be essentially a tax-cut for the wealthy with a reduction in coverage and benefits for those who are not well off. In any case, healthcare is likely to grow increasingly expensive for most Americans while they have reduced abilities to meet these expenses.

Americans are a creative and generous people, so it is not surprising that many people have turned to GoFundMe to get money to meet their medical expenses. Medical bills can be ruinous and are all too often a contributing factor in personal bankruptcy. As such, successful GoFundMe campaigns can help people pay their bills, get the care they need and avoid financial ruin. Friends of mine have been forced to undertake such campaigns and I have donated to them, as have many other people. In my own case, I am lucky—I have a job that still offers insurance coverage at a price I can afford and my modest salary allows me to easily meet the normal medical expenses for a very healthy person with no pre-existing conditions. However, I know that like most Americans, I am one bad medical disaster away from financial ruin. As such, I have followed the use of GoFundMe for medical expenses with some practical interest. I have also given it some thought from a philosophical perspective.

On the one hand, the success of certain GoFundMe campaigns to cover such expenses does suggest that people are morally decent—they are willing to expend their own resources to help other people in need. While GoFundMe does profit from such donations, their take is relatively modest for the service they provide. They are not engaged in gouging people in need and exploiting medical necessity for absurdly high profits—unlike some pharmaceutical companies.

On the other hand, there is the moral concern that in such a wealthy country replete with billionaires and millionaires, many people must resort to what amounts to begging for money to meet their medical expenses. This reality points to the excessive cost of healthcare, the relatively low earnings of many Americans, and the weakness of the nation’s safety net. While those who donate out of generosity and compassion merit moral praise, the need for such donations merits moral condemnation. In a purportedly civilized nation, people should not need to go begging for money to pay for their medical care.

To anticipate an objection, I am aware that people do use GoFundMe for frivolous things and that there are no doubt scammers using fictions of medical woe to separate the kind but uncritical from their money. Obviously enough, people are under no obligation to donate to frivolous camp and such scams are to be condemned for their wickedness. My concern is with the honest campaigns that are necessary to meet medical expenses. These are the campaigns that illustrate much that is wrong with the existing health care system.

While donating to such honest campaigns is morally laudable, there are some concerns about this method of funding. One obvious problem is that it depends on the generosity of others. It is not a systematic and dependable method of funding. As such, it is certainly problematic that some people need to rely on it.

A second obvious problem is that this method depends on an effective social media campaign to succeed. Like any other crowdfunding, success depends on getting attention and then persuading people to donate. Those who have the time, resources and skills to run effective social media campaigns (or who have such people helping them) will be far more likely to succeed than people who are lacking in these areas. This is especially concerning because people who are facing serious medical expenses are often in no condition to undertake the challenges of running such a campaign. In some cases, their efforts are being devoted to not dying. This is not to criticize or condemn people who can do this or recruit others to do it for them. Rather it, is to point out that this method is obviously no substitute for a systematic and consistent approach to funding health care.

A third obvious problem is that the success of this method depends on the appeal factor of the medical condition and the person with that condition. While a rational approach to funding would be based on merit and need, there are clearly conditions and people that are much more appealing in terms of attracting donors. For example, certain diseases and conditions can be “in vogue” and generate considerable sympathy, while others are not as appealing. In the case of people, it is evident that we are not all equal in how appealing we are to others. As with the other problems, I do not condemn or criticize people for having conditions that are in vogue or being appealing. Rather, my concern is that this method rests so heavily on these factors rather than medical and financial need. Once again, this serves to illustrate how the current system has been willfully broken and does not serve the needs of most Americans. While those who have succeeded in their GoFundMe campaigns should be lauded for their effort and ingenuity, those who run the health care system should be chastised for a state of affairs in which people have to run social media campaigns to afford their health care.

 

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Adult ADHD & Ethics

Posted in Business, Ethics, Medicine/Health, Philosophy, Politics by Michael LaBossiere on June 2, 2017


In 2017, the World Health Organization released as six question “test” for adult attention deficit hyperactivity disorder (ADHD). While even proponents of the questions warn that people should not self-diagnose with the “test”, there is the obvious question about the effectiveness of such a diagnostic method. After all, as others have noted, almost every adult seems to exhibit the symptoms that the questions ask about. For example, difficulty in concentrating, unwinding and relaxing seem to be the plight of most people. I first learned of a similar sort of diagnostic tool at a mandatory training session on learning disabilities and another faculty member commented on this tool by saying “by those standards, I think we all have ADHD.” Everyone agreed. Because of these concerns, doctors tend to agree that the simple screening test is not sufficient to diagnose adult ADHD. While using an unreliably method of diagnosing adult ADHD would be problematic, there are also important moral concerns about this matter.

Coincidentally enough, many of the doctors who served on the advisory panel for developing the screening method have enjoyed the financial support of the pharmaceutical companies who produce the drugs used to “treat” adult ADHD. Such payments to doctors by pharmaceutical companies is standard practice and drives much of how treatment works in the United States.  Doctors who are not influenced by pharmaceutical companies as less inclined to prescribe the brand name products of companies, which is hardly surprising.

It is important to note that the fact that doctors are enriched financial by pharmaceutical companies that profit from ADHD drugs does not prove that the questions are not useful nor does it prove that they are wrong in expanding the number of people on ADHD drugs. After all, the possibility that a person making a claim is biased does not entail that the claim is false and to think otherwise would be an error of logic. That said, if a person is an interested party and stands to gain, then the relevant claims should be considered with due skepticism. As such, the doctors who are pushing the agenda of the pharmaceutical companies that enrich them should be regarded as lacking in credibility to the degree they are likely to be influenced by this enrichment. Which, one would infer, would be significant.  As is always the case in such situations, what is needed are more objective sources of information about ADHD. As should not be surprising, those who are not being enriched by the industry are not as enthusiastic about expanding the ADHD drug market. This raises reasonable ethical concerns about whether the industry is profiting at the expense of people who are being pushed to use drugs they do not actually need. Given the general track record of these companies, this sort of unethical behavior does seem to be the case.

Since I am not a medical doctor specializing in ADHD, I lack the expertise to properly assess the matter. However, I can offer some rational consideration of adult ADHD and its treatment with pharmaceuticals. The diagnostic questions focus on such factors as concentration, ability to remain seated, ability to relax, ability to let people finish sentences, ability to not procrastinate, and independence in regards to ordering one’s life. As noted above, these are all things that all humans have difficulty with at one time or another. Of course, even the proponents of medicating people do note that it takes more than the usual problems to make a person a candidate for medication. But, of course, these proponents do have a fairly generous view of who should be medicated.

One reasonable concern is that there are non-pharmaceutical methods of addressing problematic behaviors of this sort. While, as noted above, I am not an ADHD specialist, I do have extensive training in methods of concentration (thanks to running, martial arts and academics). As such, I know that people can be trained to have better focus without the use of profitable chemicals. Since these drugs have side effects and cost money, it would be morally and practically preferable to focus on non-chemical methods of developing positive traits. Aristotle developed just such a method long ago: training in virtue by habituation. But, it can be objected, there are people who cannot or will not use such non-pharmaceutical methods.

This is a reasonable reply. After all, while many medical conditions can be addressed without drugs, there are times when drugs are the only viable options—such as in cases of severe bacterial infections. However, there is still an important concern: are the drugs merely masking the symptoms of an underlying problem?

In the United States, most adults do not get enough sleep and are under considerable stress. This is due, largely, to the economic system that we accept and tolerate. It is well known that lack of sleep and stress cause exactly the sort of woes that are seen as symptoms of adult ADHD. As such, it seems reasonable to think that problematic adult ADHD is largely the result of the American way of life. While the drugs mask the real problems, they do not solve them. In fact, these drugs can be seen as analogous to the soma of Aldous Huxley’s Brave New World. If this is true, then the treatment of ADHD with drugs is morally problematic in at least two ways. First, it does not really treat the problems—it merely masks them and leaves the real causes in place. Second, drugging people in this manner makes it easier for them to tolerate a political, social and economic system that is destroying them which is morally wrong. In light of the above discussion, the pushing of ADHD drugs on adults is morally wrong.

 

 

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Opioids, Heart Surgery & Ethics

Posted in Ethics, Medicine/Health, Philosophy by Michael LaBossiere on March 24, 2017

While pharmaceutical companies and their stockholders have profited greatly from flooding America with opioids, this has come at a terrible cost to others. Showing that the idea of gateway drugs can prove true, there has proven to be a clear path from legal opioids to illegal opioids (such as heroin). As would be expected, the use of opioids can have a terrible impact on health. One example of this is endocarditis.

Endocarditis is, roughly speaking, an abscess on a heart valve. While not limited to drug users, it is not an uncommon consequence of injecting opioids. Since the abuse of opioids is increasing, it is no surprise that the number of drug users suffering from endocarditis has increased significantly.  As would be imagined, the treatment of endocarditis involves a very expensive surgery. As would also be imagined, many of the drug users getting this surgery are on Medicaid, so the taxpayers are footing the bill for this expensive treatment. To make matters worse, people typically return to using opioids after the surgery and this often results in the need for yet another expensive surgery, paid for by Medicaid. This does raise some serious moral concerns.

There is, of course, the very broad moral issue of whether Medicaid should exist. On the one hand, a compelling moral argument can be made that just as a nation provides military and police protection to citizens who cannot afford their own security forces or bodyguards, a nation should fund medical care for those who cannot afford it on their own. On the other hand, a moral argument can be made that a nation has no obligation to provide such support and that citizens should be left to fend for themselves in regards to health care. Naturally enough, if the nation is under no obligation to provide Medicaid in general, then it is under no obligation to cover the cost of the surgery in question. On this view, there is no need to consider the matter further.

However, it does seem worth granting for the sake of argument that the state should provide Medicaid and then consider the ethics of paying for endocarditis surgery for opioid addicts. Especially when they are likely to continue the behavior that resulted in the need for surgery. It is to this discussion that I now turn.

While it certainly appears harsh to argue against paying for addict’s heart surgery, a solid moral case can be made in favor of this position. The easiest and most obvious way to do this is on utilitarian grounds.

As noted above, the surgery for endocarditis is very expensive. As such, it uses financial and medical resources that could be used elsewhere. It seems likely that a great deal of good could be done with those resources that exceed the good created by replacing the heart valve of an addict. This argument can be strengthened by including the fact that addicts often return to the very behavior that resulted in endocarditis, thus creating the need for repeating the costly surgery. From a utilitarian perspective, it would be morally better to use those resources to treat patients who are far less likely to willfully engage in behavior that will require them to be treated yet again. This is because the resources that would be consumed treating and retreating a person who keeps inflicting harm on themselves could be used to treat many people, thus doing greater good for the greater number. Though harsh and seemingly merciless, this approach seems justifiable on grounds similar to the moral justification for triage.

Another approach, which is even harsher, is to focus on the fact that the addicts inflicting endocarditis on themselves and often doing so repeatedly. This provides the basis for two arguments against public funding of their treatment.

One argument can be built around the idea that there is not a moral obligation to help people when their harm is self-inflicted. To use an analogy, if a person insists on setting fire to their house and it burns down, no one has a moral responsibility to pay to have their house rebuilt. Since the addict’s woes are self-inflicted, there is no moral obligation on the part of others to pay for their surgery and forcing people to do so (by using public money) would be like forcing others to pay to rebuild the burned house.

One way to counter this is to point out that a significant percentage (probably most) health issues are self-inflicted by a lack of positive behavior (such as exercise and a good diet) and an abundance of negative behavior (such as smoking, drinking, or having unprotected sex). As such, if this principle is applied to addicts in regards to Medicaid, it must be applied to all cases of self-inflicted harms. While some might take this as a refutation of this view, others might accept this as quite reasonable.

Another argument can be built around the notion that while there could be an obligation to help people, this obligation has clear limits. In this case, if a person is treated and then knowingly returns to the same behavior that inflicted the harm, then there is no obligation to keep treating the person. In the case of the drug addict, it could be accepted that the first surgery should be covered and that they should be educated on what will happen if they persist in their harmful behavior. If they then persist in that behavior and need the surgery again, then public money should not be used. To use an analogy, if a child swings their ice cream cone around playing like it is a light sabre and is surprised when the scoops are flung to the ground, then it would reasonable for the parents to buy the child another cone. If the child then swings the new cone around again and the scoops hit the floor, then the child can be justly denied another cone.

An obvious counter is to contend that addicts are addicted and hence cannot be blamed for returning to the same behavior that caused the harm. That is, they are not morally responsible for what they are doing to themselves because they cannot do otherwise. This does have some appeal, but would seem to enable the justification of requiring addicts to undergo treatment for their addiction and to agree to monitoring of their behavior. They should be free to refuse this (which, ironically, assumes they are capable of free choice), but this should result in their being denied a second surgery if their behavior results in the same harm. Holding people accountable does seem to be cruel, but the alternative is unfair to other citizens. It would be like requiring them to keep rebuilding houses for a person who persists in setting fires in their house and refuses to have sprinklers installed.

These arguments can be countered by arguing that there is an obligation to provide such care regardless of how many times an addict returns to the behavior that caused the need for the surgery. One approach would be to build an analogy based on how the state repeatedly bails out big businesses every time they burn down the economy. Another approach would be to appeal to the value of human life and contend that it must be preserved regardless of the cost and regardless of the reason why there is a need for the medical care. This approach could be noble or, perhaps, foolish.

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Medicine & Markets

Posted in Ethics, Medicine/Health, Philosophy, Politics by Michael LaBossiere on March 22, 2017

As a point of ideology, many conservatives advocate the broad application of free market principles. One key part of this ideology is the opposition of regulation, at least regulation that does not favor businesses. Since health care is regarded as a business in the United States, there is an interesting question in regards to the extent that health care pricing should be regulated by the state.

Because of the high cost of health care in the United States, there have been proposals to place limits on the cost of health care services. Some areas have implemented such proposals, but there is a general lack of such regulations on pricing. Those who oppose such regulations often contend that pricing should be set by free competition between health care providers and that consumers of health care should be savvy shoppers. The idea is that savvy health care shoppers will take their business to providers that offer better services or lower costs, which will force the competition to lower costs or improve quality.

There are various problems with the idea of savvy health care shoppers. The first is the challenge consumers face in finding the prices that health care providers charge. While it can be difficult to predict what services a consumer might need, health care providers often have a range of prices depending on who is paying for the services. For example, insurance companies negotiate prices with providers and these differ from what consumers without insurance would pay. Health care providers, although they always have a database of billing codes and costs, are generally reluctant to provide this information. This makes savvy shopping difficult.

A second problem is that health care consumers typically lack the medical knowledge to make informed decisions about health care. While a person might have some challenge in sorting out what sort of phone or laptop they should buy, sorting out what sort of medical care they might really need is typically beyond the skill of most people. That is why people go to medical professionals. As such, being a savvy shopper is rather difficult.

A third problem is that it is something of a mistake to describe a health care consumer as a consumer; it is usually more apt to call them a patient. While this might seem to be a mere difference in labels, the difference between consumer and patient is significant.

A rather important difference is that a patient is typically in duress—they are injured or ill and thus not in a very good state to engage in savvy shopping practices. While an informed rational consumer will be looking for the best deal, a suffering patient is concerned primarily with getting better. As people say to not go grocery shopping on an empty stomach, it would be best to not shop for health care when one is not healthy—but that is exactly when one needs health care. There are also the more extreme cases. For example, a person who is badly injured in a car crash is not going to be shopping in a savvy manner for emergency rooms as they are being transported in the ambulance.

It can be countered that there are cases in which a person can engage in savvy shopping, such as elective surgeries and non-emergencies. This is a reasonable point—a person who is not in dire need can take the time to shop around and be a savvy consumer. However, this does not apply to cases in which a person is sick or injured enough to impeded such savvy shopping.

Another important difference between consumer and patient is that the consumer often has a reasonable choice between buying a good or service and doing without. In contrast, patients usually have a real need for the good or service and doing without would be a real hardship or even fatal. When one must buy the good or service and the provider knows this, it makes it much harder to be a savvy shopper. This also provides a segue into the matter of regulating prices.

While free market pricing can work when consumers can easily do without the good or service, it runs into obvious problems for the consumer when the goods or services are necessities. To the degree that the patient cannot do without the health care goods or services, the patient is at the mercy of the provider. So, while a person can easily elect to do without the latest iPhone if they cannot afford it, it is much more difficult for a person to do without their chemotherapy or AIDS medication. True, a consumer could do without liposuction or breast implants, but such elective surgery differs from non-elective treatments.

The stock counter to such concerns is that if a consumer finds the price of a good or service too high, they can go to a lower priced competitor. Assuming, of course, that there is real competition. In the case of health care, the opportunity to find a lower priced competitor can be problematic. A patient might not have the time to shop around on the way to an emergency room. In many places, there is not any local competition with lower prices. As such, this free market advice is not very helpful.

In the case of pharmaceuticals, patients often find that there is no competition. When a company has a patent on a medication, the United States’ government uses its coercive power to enforce that patent, ensuring that the company retains a monopoly on that medication. Because of this, a patient who needs the medication has two basic choices: do without or pay the price. There is no free market competition, so without regulation on the part of the state, the company can decide to charge whatever is desired—subject to the cost of bad press, of course.

This monopoly system does create something of a quandary for a principled proponent of the free market. On the one hand, without such patents a free market of drugs would make it irrational for for-profit companies to invest in costly research. This is because as soon as the drug was developed, the competition would just duplicate it and can sell it cheaper because they would not need to recoup the cost of development. A solution, which would not be very free market, would be to have the state fund the expensive research and then provide the results to companies who would then compete without monopolies for consumer dollars. Another “solution” would be to let the market remain free and hope that medications would somehow be developed.

On the other hand, if the state stepped in to regulate prices as part of the agreement for using its coercive power to protect the monopoly, then there would also be no free market competition. But, the state could see to it that the companies charged prices that allowed profits while not gouging patients.

My own view, as might be suspected, is that since patients are essentially a coerced market when it comes to health care and medication, the state should act to regulate prices. In the case of pharmaceutical companies, this should be part of the bargain with the state that allows them to maintain their monopolies. After all, if taxpayer dollars are to be used to protect monopolies, then they should get something in return—and this something should be reasonably priced medication. In the case of health care providers, while they do not usually have a monopoly, they do have a coerced market. Just as the state justly steps in to prevent price gouging during large scale natural disasters, it can justly do so in regards to personal disasters—that is, injury and illness.

I am certainly sensitive of the desire of health care providers and pharmaceutical companies to make a profit and, as such, I would certainly advocate that the regulations on pricing leave them a reasonable margin of profit. While it might be objected that a reasonable margin of profit it hard to define, my reply is that if price gouging can be recognized in other areas, it can (and is) be recognized in the realm of medicine.

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The State & Health Care

Posted in Ethics, Law, Medicine/Health, Philosophy, Politics by Michael LaBossiere on March 13, 2017

One way to argue that the state is obligated to provide health care (in some manner) to its citizens is to draw an analogy to the obligation of the state to defend its citizens from “enemies foreign and domestic.” While thinkers disagree about the obligations of the state, almost everyone except the anarchists hold that the state is required to provide military defense against foreign threats and police against domestic threats. This seems to be at least reasonable, though it can be debated. So, just as the United States is obligated to defend its citizens from the Taliban, it is also obligated to defend them against tuberculous.

Another approach is to forgo the analogy and argue that the basis of the obligation to provide military defense and police services also extends to providing health care. The general principle at hand is that the state is obligated to protect its citizens. Since anthrax and heart failure can kill a person just as dead as a bullet or a bomb, then the state would seem to be obligated to provide medical protection in addition to police and military protection. Otherwise, the citizens are left unguarded from a massive threat and the state would fail in its duty as a protector. While these lines of reasoning are appealing, they can certainly be countered. This could be done by arguing that there are relevant differences between providing health care and providing armed defenses.

One way to do this is to argue that the state is only obligated to protect its citizens from threats presented by humans and not from other threats to life and health, such as disease, accidents or congenital defects. So, the state is under no obligation to protect citizens from the ravages of Alzheimer’s. But, if ISIS or criminals developed a weapon that inflicted Alzheimer’s on citizens, then the state would be obligated to protect the citizens.

On the face of it, this seems odd. After all, from the standpoint of the victim it does not seem to matter whether their Alzheimer’s is “natural” or inflicted—the effect on them is the same. What seems to matter is the harm being inflicted on the citizen. To use an obvious analogy, it would be like the police being willing to stop a human from trying to kill another human, but shrugging and walking away if they see a wild animal tearing apart a human. As such, it does not matter whether the cause is a human or, for example, a virus—the state’s obligation to protect citizens would still apply.

Another approach is to argue that while the state is obligated to protect its citizens, it is only obligated to provide a certain type of defense. The psychology behind this approach can be made clear by the rhetoric those who favor strong state funding for the military and police while being against state funding for medical care. The military is spoken of in terms of its importance in “degrading and destroying” the enemy and the police are spoken of in terms of their role in imposing “law and order.” These are very aggressive roles and very manly. One can swagger while speaking about funding submarines, torpedoes, bullets and missiles.

In contrast, the rhetoric against state funding of health care speaks of “the nanny state” and how providing such support will make people “weak” and “dependent.” This is caring rather than clubbing, curing rather than killing. One cannot swagger about while speaking about funding preventative care and wellness initiatives.

What lies behind this psychology and rhetoric is the principle that the state’s role in protecting its citizens is one of force and violence, not one of caring and curing. This does provide a potential relevant difference; but the challenge is showing that this difference warrants providing armed defense while precluding providing medical care.

One way to argue against it is to use an analogy to a family. Family members are generally obligated to protect one another, but if it were claimed that this obligation was limited only to using force and not with caring for family members, then this would be rightfully regarded as absurd.

Another approach is to embrace the military and police metaphors. Just as the state should thrust its force against enemies within and without, it should use its medical might to crush foes that are literally within—within the citizens. So, the state could wage war on viruses, disease and such and thus make it more manly and less nanny. This should have some rhetorical appeal to those who love military and police spending but loath funding healthcare. Also to those who are motivated by phallic metaphors.

As far as the argument that health care should not be provided by the state because it will make people dependent and weak, the obvious reply is that providing military and police protection would have the same impact. As such, if the dependency argument works against health care, it would also work against having state military and police. If people should go it on their own in regards to health care, then they should do the same when it comes to their armed defense. If private health coverage would suffice, then citizens should just arm themselves and provide their own defense and policing. This, obviously enough, would be a return to the anarchy of the state of nature and that seems rather problematic. If accepting military and police protection from the state does not make citizens weak and dependent, then the same should also hold true for accepting health care from the state.

As a final point, an easy way to counter the obligation argument for state health care is to argue that the state is not obligated to provide military and police protection to the citizens. Rather, the military and the military, it could be argued, exists to protect and advance the interests of the elites. Since the elites have excellent health care thanks to their wealth and power, there is no need for the state to provide it to them. Other than the elites in government, like Paul Ryan and Trump, who get their health care from the state, of course. On this view, support for using public money for the military and police and not health care makes perfect sense.

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Antibiotics & the Cost of Agriculture

Posted in Business, Environment, Ethics, Law, Medicine/Health, Philosophy by Michael LaBossiere on May 23, 2016

Modern agriculture does deserve considerable praise for the good that it does. Food is plentiful, relatively cheap and easy to acquire. Instead of having to struggle with raising crops and livestock or hunting and gathering, I can simply drive to the supermarket and stock up with the food I need to not die. However, as with all things, there is a price.

The modern agricultural complex is now highly centralized and industrialized, which does have its advantages and disadvantages. There are also the harms of specific, chosen practices aimed at maximizing profits. While there are many ways to maximize profits, two common ones are to pay the lowest wages possible (which the agricultural industry does—and not just to the migrant laborers, but to the ranchers and farmers) and to shift the costs to others. I will look, briefly, at one area of cost shifting: the widespread use of antibiotics in meat production.

While most people think of antibiotics as a means of treating diseases, food animals are now routinely given antibiotics when they are healthy. One reason for this is to prevent infections: factory farming techniques, as might be imagined, vastly increase the chances of a disease spreading like wildfire among an animal population. Antibiotics, it is claimed, can help reduce the risk of bacterial infections (antibiotics are useless against viruses, of course). A second reason is that antibiotics increase the growth rate of healthy animals, allowing them to pack on more meat in less time—and time is money. These uses allow the industry to continue factory farming and maintain high productivity—which initially seems laudable. The problem is, however, that this use of antibiotics comes with a high price that is paid for by everyone else.

Eric Schlosser wrote “A Safer Food Future, Now”, which appeared in the May 2016 issue of Consumer Reports. In this article, he notes that this practice has contributed significantly to the rise of antibiotic resistant bacteria. Each year, about two million Americans are infected with resistant strains and about 20,000 die. The healthcare cost is about $20 billion. To be fair, the agricultural industry is not the only contributor to this problem: improper use of antibiotics in humans has also added to this problem. That said, the agricultural use of antibiotics accounts for about 75% of all antibiotic usage in the United States, thus converting the factory farms into for resistant bacteria.

The harmful consequences of this antibiotic use have been known for years and there have, not surprisingly, been attempts to address this through legislation. It should, however, come as little surprise that our elected leaders have failed to take action. One likely explanation is that the lobbying on the part of the relevant corporations has been successful in preventing action. After all these is a strong incentive on the part of industry to keep antibiotics in use: this increases profits by enabling factory farming and the faster growth of animals. That said, it could be contended that the lawmakers are ignorant of the harms, doubt there are harms from antibiotics or honestly believe that the harms arising from their use are outweighed by the benefits to society. That is, the lawmakers have credible reasons other than straight up political bribery (or “lobbying” as it is known in polite company). This is a factual matter, albeit one that is difficult to settle: no professional politician who has been swayed by lobbying will attribute her decision to any but the purist of motivations.

This matter is certainly one of ethical concern and, like most large scale ethical matters that involves competing interests, is one that seems best approached by utilitarian considerations. On the side of using the antibiotics, there is the increased productivity (and profits) of the factory farming system of producing food. This allows more and cheaper food to be provided to the population, which can be regarded as pluses. The main reasons to not use the antibiotics, as noted above, are that they contribute to the creation of antibiotic resistant strains that sicken and kill many people (vastly more Americans than are killed by terrorism). This inflicts considerable costs on the sickened and those who are killed as well as those who care about them. There are also the monetary costs in the health care system (although the increased revenue can be tagged as a plus for health care providers). In addition to these costs, there are also other social and economic costs, such as lost hours of work. As this indicates, the cost (illness, death, etc.) of the use of the antibiotics is shifted: the industry does not pay these costs, they are paid by everyone else.

Using a utilitarian calculation requires weighing the cost to the general population against the profits of the industry and the claimed benefits to the general population. Put roughly, the moral question is whether the improved profits and greater food production outweigh the illness, deaths and costs suffered by the public. The people in the government seem to believe that the answer is “yes.”

If the United States were in a food crisis in which the absence of the increased productivity afforded by antibiotics would cause more suffering and death than their presence, then their use would be morally acceptable. However, this does not seem to be the case—while banning this sort of antibiotic use would decrease productivity (and impact profits), the harm of doing this would seem to be vastly exceeded by the reduction in illness, deaths and health care costs. However, if an objective assessment of the matter showed that the ban on antibiotics would not create more benefits than harms, then it would be reasonable and morally acceptable to continue to use them. This is partially a matter of value (in terms of how the harms and benefits are weighted) and partially an objective matter (in terms of monetary and health costs). I am inclined to agree that the general harm of using the antibiotics exceeds the general benefits, but I could be convinced otherwise by objective data.

 

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A Patient’s Right to Know

Posted in Ethics, Medicine/Health, Philosophy by Michael LaBossiere on April 29, 2016

English: Livingston, TX, 9/25/05 -- A doctor t...

All professions have their problem members and the field of medicine is no exception. Fortunately, the percentage of bad doctor is rather low—but this small percentage can do considerable harm. After all, when your professor is incompetent, you might not learn as much as you should. If your doctor is incompetent, she could kill you.

The May, 2016 issue of Consumer Reports includes a detailed article by Rachel Rabkin Peachman covering the subject of bad doctors and the difficulty patients face in learning whether a physician is a good doctor or a disaster.

Based on the research in the article, there are three main problems. The first is that there are bad doctors. The article presents numerous examples to add color to the dry statistics and this include such tales of terror as doctors molesting patients, doctors removing healthy body parts, and patient deaths due to negligence, impairment or incompetence. These are obvious all moral and professional failings on part of the doctors and they should clearly not be engaged in such misdeeds.

The second is that, according to Peachman, the disciplinary actions taken by the profession tend to be rather less than ideal. While doctors should enjoy the protection of a due process, the hurdles are, perhaps, too high. There is also the problem that the responses to the misdeeds are often very mild. For example, a doctor whose negligence has resulted in the death of patients can be allowed to keep practicing with only minor limitations. As another example, a doctor who has engaged in sexual misconduct might continue practicing after a class or two on ethics and with the requirement that someone else be present when he is seeing patients. In addition to the practical concerns about this, there is also the moral concern that the disciplinary boards are failing to protect patients.

One possible argument against harsher punishments is that there is a shortage of doctors and taking a doctor out of practice would have worse consequences than allowing a bad doctor to keep practicing. This would be the basis for a utilitarian argument for continuing mild punishments. Crudely put, it is better to have a doctor who might kill a patient or two than no doctor at all.

This argument does have some appeal. However, there is the factual question of whether or not the mild punishments do more good than harm. If they do, then one would need to accept that this approach is morally tolerable. If not, then the argument would fail. There is also the response that consequences are not what matters—people should be reprimanded based on their misdeeds and not based on some calculation of utility. This also has some intuitive appeal.

It could also be argued that it should be left to patients to judge if they want to take the risk. If a doctor is known for sexual misdeeds with female patients but is fine with male patients, then a man who has few or no other options might decide that the doctor is his best choice. This leads to the third problem.

The third problem is that it is very difficult for patients to learn about bad doctors. While there is a National Practitioner Data Bank (NPDB), it is off limits to patients and is limited to people in law enforcement, hospital administration, insurance and a few other groups.

The main argument advanced against allowing public access to the NPDB is based on the premise that it contains inaccurate information which could be harmful to innocent doctors. Interestingly enough, this makes it similar to the credit report data—it is notorious for containing harmful inaccuracies that can plague people.

While the possibility of incorrect data is a matter of concern, that premise best supports the conclusion that the NPDB should be reviewed regularly to ensure that the information is accurate. While perfect accuracy is not possible, it would seem to be well within the realm of possibility for the information to meet a reasonable standard of accuracy. This could be aided by providing robust tools for doctors to inform those running the NPDB of errors and to inform doctors about the content of their files. As such, the error argument is easily defeated.

Patients do have some access to data about doctors, but there are many barriers in place. In some cases, there is a financial cost to access data. In almost all cases, the patient will need to grind through lengthy documents and penetrate the code of legalize. There is also the fact that this data is often incomplete and inaccurate.  While it could be argued that a responsible patient would expend the resources needed to research a doctor, this seems to be an unreasonable request—a patient should not need to do all this just to know that the doctor is competent. A reason for this is that a patient might be in rough shape and expecting her to engage in all this work would seem unfair. There is also the fact that one legitimate role of the state is to protect citizens from harm and having a clear means of identifying bad doctors would seem to fall within this.

Given the above, it seems reasonable to accept that a patient has the right to know about her doctor’s competence and should have an easy means of acquiring accurate information. This enables a patient to make an informed choice about her physician without facing an undue burden. This will also help the profession—good doctors will attract more patients and bad doctors will have a greater incentive to improve their practice.

 

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My Old Husky & Philosophy III: Experiments & Studies

Posted in Medicine/Health, Philosophy, Reasoning/Logic by Michael LaBossiere on April 8, 2016

Isis on the GoWhile my husky, Isis, and I have both slowed down since we teamed up in 2004, she is doing remarkably well these days. As I often say, pulling so many years will slow down man and dog. While Isis faced a crisis, most likely due to the wear of time on her spine, the steroids seemed to have addressed the pain and inflammation so that we have resumed our usual adventures. Tail up and bright eyed is the way she is now and the way she should be.

In my previous essay I looked at using causal reasoning on a small sale by applying the methods of difference and agreement. In this essay I will look at thinking critically about experiments and studies.

The gold standard in science is the controlled cause to effect experiment. The objective of this experiment is to determine the effect of a cause. As such, the question is “I wonder what this does?” While the actual conducting of such an experiment can be complicated and difficult, the basic idea is rather simple. The first step is to have a question about a causal agent. For example, it might be wondered what effect steroids have on arthritis in elderly dogs. The second step is to determine the target population, which might already be taken care of in the first step—for example, elderly dogs would be the target population. The third step is to pull a random sample from the target population. This sample needs to be representative (that is, it needs to be like the target population and should ideally be a perfect match in miniature). For example, a sample from the population of elderly dogs would ideally include all breeds of dogs, male dogs, female dogs, and so on for all relevant qualities of dogs. The problem with a biased sample is that the inference drawn from the experiment will be weak because the sample might not be adequately like the general population. The sample also needs to be large enough—a sample that is too small will also fail to adequately support the inference drawn from the experiment.

The fourth step involves splitting the sample into the control group and the experimental group. These groups need to be as similar as possible (and can actually be made of the same individuals). The reason they need to be alike is because in the fifth step the experimenters introduce the cause (such as steroids) to the experimental group and the experiment is run to see what difference this makes between the two groups. The final step is getting the results and determining if the difference is statistically significant. This occurs when the difference between the two groups can be confidently attributed to the presence of the cause (as opposed to chance or other factors). While calculating this properly can be complicated, when assessing an experiment (such as a clinical trial) it is easy enough to compare the number of individuals in the sample to the difference between the experimental and control groups. This handy table from Critical Thinking makes this quite easy and also shows the importance of having a large enough sample.

 

Number in Experimental Group

(with similarly sized control group)

Approximate Figure That the difference Must Exceed

To Be Statistically Significant

(in percentage points)

10 40
25 27
50 19
100 13
250 8
500 6
1,000 4
1,500 3

 

Many “clinical trials” mentioned in articles and blog posts have very small samples sizes and this often makes their results meaningless. This table also shows why anecdotal evidence is fallacious: a sample size of one is all but completely useless when it comes to an experiment.

The above table also assumes that the experiment is run correctly: the sample was representative, the control group was adequately matched to the experimental group, the experimenters were not biased, and so on for all the relevant factors. As such, when considering the results of an experiment it is important to consider those factors as well. If, for example, you are reading an article about an herbal supplement for arthritic dogs and it mentions a clinical trial, you would want to check on the sample size, the difference between the two groups and determine whether the experiment was also properly conducted. Without this information, you would need to rely entirely on the credibility of the source. If the source is credible and claims that the experiment was conducted properly, then it would be reasonable to trust the results. If the source’s credibility is in question, then trust should be withheld. Assessing credibility is a matter of determining expertise and the goal is to avoid being a victim of a fallacious appeal to authority. Here is a short checklist for determining whether a person (or source) is an expert or not:

 

  • The person has sufficient expertise in the subject matter in question.
  • The claim being made by the person is within her area(s) of expertise.
  • There is an adequate degree of agreement among the other experts in the subject in question.
  • The person in question is not significantly biased.
  • The area of expertise is a legitimate area or discipline.
  • The authority in question must be identified.

 

While the experiment is the gold standard, there are times when it cannot be used. In some cases, this is a matter of ethics: exposing people or animals to something potentially dangerous might be deemed morally unacceptable. In other cases, it is a matter of practicality or necessity. In such cases, studies are used.

One type of study is the non-experimental cause to effect study. This is identical to the cause to effect experiment with one rather critical difference: the experimental group is not exposed to the cause by those running the study. For example, a study might be conducted of dogs who recovered from Lyme disease to see what long term effects it has on them.

The study, as would be expected, runs in the same basic way as the experiment and if there is a statistically significant difference between the two groups (and it has been adequately conducted) then it is reasonable to make the relevant inference about the effect of the cause in question.

While useful, this sort of study is weaker than the experiment. This is because those conducting the study have to take what they get—the experimental group is already exposed to the cause and this can create problems in properly sorting out the effect of the cause in question. As such, while a properly run experiment can still get erroneous results, a properly run study is even more likely to have issues.

A second type of study is the effect to cause study. It differs from the cause to effect experiment and study in that the effect is known but the cause is not. Hence, the goal is to infer an unknown cause from the known effect. It also differs from the experiment in that those conducting the study obviously do not introduce the cause.

This study is conducted by comparing the experimental group and the control group (which are, ideally, as similar as possible) to sort out a likely cause by considering the differences between them. As would be expected, this method is far less reliable than the others since those doing the study are trying to backtrack from an effect to a cause. If considerable time has passed since the suspected cause, this can make the matter even more difficult to sort out. The conducting the study also have to work with the experimental group they happen to get and this can introduce many complications into the study, making a strong inference problematic.

An example of this would be a study of elderly dogs who suffer from paw knuckling (the paw flips over so the dog is walking on the top of the paw) to determine the cause of this effect. As one might suspect, finding the cause would be challenging—there would be a multitude of potential causes in the history of the dogs ranging from injury to disease. It is also quite likely that there are many causes in play here, and this would require sorting out the different causes for this same effect. Because of such factors, the effect to cause study is the weakest of the three and supports the lowest level of confidence in its results even when conducted properly. This explains why it can be so difficult for researchers to determine the causes of many problems that, for example, elderly dogs suffer from.

In the case of Isis, the steroids that she is taking have been well-studied, so it is quite reasonable for me to believe that they are a causal factor in her remarkable recovery. I do not, however, know for sure what caused her knuckling—there are so many potential causes for that effect. However, the important thing is that she is now walking normally about 90% of the time and her tail is back in the air, showing that she is a happy husky.

 

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Philosophy & My Old Husky II: Difference & Agreement

Posted in Medicine/Health, Philosophy, Reasoning/Logic by Michael LaBossiere on April 6, 2016

Isis in the mulchAs mentioned in my previous essay, Isis (my Siberian husky) fell victim to the ravages of time. Once a fast sprinting and long running blur of fur, she now merely saunters along. Still, lesser beasts fear her (and to a husky, all creatures are lesser beasts) and the sun is warm—so her life is still good.

Faced with the challenge of keeping her healthy and happy, I have relied a great deal on what I learned as a philosopher. As noted in the preceding essay, I learned to avoid falling victim to the post hoc fallacy and the fallacy of anecdotal evidence. In this essay I will focus on two basic, but extremely useful methods of causal reasoning.

One of the most useful tool for causal reasoning is the method of difference. This method was famously developed by the philosopher John Stuart Mill and has been a staple in critical thinking classes since way before my time. The purpose of the method is figuring out the cause of an effect, such as a husky suffering from a knuckling paw (a paw that folds over, so the dog is walking on the top of the foot rather than the bottom). The method can also be used to try to sort out the effect of a suspected cause, such as the efficacy of an herbal supplement in treating canine arthritis.

Fortunately, the method is quite simple. To use it, you need at least two cases: one in which the effect has occurred and one in which it has not. In terms of working out the cause, more cases are better—although more cases of something bad (like arthritis pain) would certainly be undesirable from other standpoints. The two cases can actually involve the same individual at different times—it need not be different individuals (though it also works in those cases as well). For example, when sorting out Isis’ knuckling problem the case in which the effect occurred was when Isis was suffering from knuckling and the case in which it did not was when Isis was not suffering from this problem. I also looked into other cases in which dogs suffered from knuckling issues and when they did not.

The cases in which the effect is present and those in which it is absent are then compared in order to determine the difference between the cases. The goal is to sort out which factor or factors made the difference. When doing this, it is important to keep in mind that it is easy to fall victim to the post hoc fallacy—to conclude without adequate evidence that a difference is a cause because the effect occurred after that difference. Avoiding this mistake requires considering that the “connection” between the suspected cause and the effect might be purely a matter of coincidence. For example, Isis ate some peanut butter the day she started knuckling, but it is unlikely that had any effect—especially since she has been eating peanut butter her whole life. It is also important to consider that an alleged cause might actually be an effect caused by a factor that is also producing the effect one is concerned about. For example, a person might think that a dog’s limping is causing the knuckling, but they might both be effects of a third factor, such as arthritis or nerve damage. You must also keep in mind the possibility of reversed causation—that the alleged cause is actually the effect. For example, a person might think that the limping is causing the knuckling, but it might turn out that the knuckling is the cause of the limping.

In some cases, sorting out the cause can be very easy. For example, if a dog slips and falls, then has trouble walking, then the most likely cause is the fall (but it could still be something else—perhaps the fall and walking trouble were caused by something else). In other cases, sorting out the cause can be very difficult. It might be because there are many possible causal factors. For example, knuckling can be caused by many things (apparently even Lyme disease). It might also be because there are no clear differences (such as when a dog starts limping with no clear preceding event). One useful approach is to do research using reliable sources. Another, which is a good idea with pet problems, is to refer to an expert—such as a vet. Medical tests, for example, are useful for sorting out the difference and finding a likely cause.

The same basic method can also be used in reverse, such as determining the effectiveness of a dietary supplement for treating canine arthritis. For example, when Isis started slowing down and showing signs of some soreness, I started giving her senior dog food, glucosamine and some extra protein. What followed was an improvement in her mobility and the absence of the signs of soreness. While the change might have been a mere coincidence, it is reasonable to consider that one or more of these factors helped her. After all, there is some scientific evidence that diet can have an influence on these things. From a practical standpoint, I decided to keep to this plan since the cost of the extras is low, they have no harmful side effects, and there is some indication that they work. I do consider that I could be wrong. Fortunately, I do have good evidence that the steroids Isis has been prescribed work—she made a remarkable improvement after starting the steroids and there is solid scientific evidence that they are effective at treating pain and inflammation. As such, it is rational to accept that the steroids are the cause of her improvement—though this could also be a coincidence.

The second method is the method of agreement. Like difference, this requires at least two cases. Unlike difference, the effect is present in all the cases. In this method, the cases exhibiting the effect (such as knuckling) are considered in order to find a common thread in all the cases. For example, each incident of knuckling would be examined to determine what they all have in common. The common factor (or factors) that is the most plausible cause of the effect is what should be taken as the likely cause. As with the method of difference, it is important to consider such factors as coincidence so as to avoid falling into a post hoc fallacy.

The method of agreement is most often used to form a hypothesis about a likely cause. The next step is, if possible, to apply the method of difference by comparing similar cases in which the effect did not occur. Roughly put, the approach would be to ask what all the cases have in common, then determine if that common factor is absent in cases in which the effect is also absent. For example, a person investigating knuckling might begin by considering what all the knuckling cases have in common and then see if that common factor is absent in cases in which knuckling did not occur.

One of the main weaknesses of these methods is that they tend to have very small sample sizes—sometimes just one individual, such as my husky. While these methods are quite useful, they can be supplemented by general causal reasoning in the form of experiments and studies—the subject of the next essay in this series.

 

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