A Philosopher's Blog

Opioids, Heart Surgery & Ethics

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

Posted in Ethics, Philosophy by Michael LaBossiere on October 10, 2016

English: A homeless man in Paris Français : Un...

The United States, like all societies, suffers from a range of ills. This include such things as mental illness, homelessness and drug addiction. There are, of course, many ways that these problems could be addressed. Unfortunately, the dominant approach has been to recast these ills as problems to be solved by law enforcement and criminalization. I will briefly consider the failures of this approach in these cases.

In the 1980s there was a major shift in America’s policy regarding mental illness: in the name of fiscal savings, the mentally ill were released from the hospitals into the community. One major impact of this change was an increase in the number of homeless people. 20-25% of the homeless suffer from severe mental illness, compared to 6% of the entire population. The mentally ill who are homeless, as one might suspect, are generally not treated. People with untreated severe mental illnesses often behave in ways that the public finds problematic, which often leads to their being arrested and imprisoned. Prisons are ill-equipped to deal with the mentally ill and mainly serve to warehouse these people until they serve their sentences. Having a criminal record simply makes matters worse, thus it is likely that they will simply be returned to prison and remain untreated—thus creating a hopeless cycle which offers little chance for escape.

The criminalization of mental illness has not solved the problem, rather it has made it worse. As such, it is a failure from a practical standpoint. It has not helped treat people and the cost of operating mental health institutions has been replaced with the cost of maintaining prisons. Perhaps someone does profit from this system; but it costs society as a whole a great deal.

It is also a moral failure. On utilitarian grounds, it is morally wrong because it has increased rather than decreased unhappiness. Put informally, it has done more harm than good. For moral systems that focus on obligations to the wellbeing of others (such as the version of Christianity that embraces the parable of the good Samaritan), this approach is also a moral failure. As such, criminalizing mental illness has proven a resounding failure.

While mental illness leads many to the streets, America’s economic system also generates a large number of homeless people. Many of the homeless end up that way due to being bankrupted by medical expenses. Since the homeless have no homes, they tend to live and sleep in public areas. As would be expected, the presence of the homeless in such areas is regarded as a problem and some cities try to address the matter by criminalizing such things as lying down or camping in public areas. The ordinances that do this typically impose fines, but since the homeless generally cannot afford to pay fines they usually end up in the criminal justice system—which is often a pathway to prison. A criminal record only makes matters worse for the homeless and increases the chance they will remain homeless. This means that they are likely to be arrested again for breaking the ordinances that target the homeless, thus creating a vicious circle.

As might be suspected, this approach to homelessness comes with a significant monetary cost. For example, Denver spent over $750,000 enforcing its homeless targeting ordinances. Other cities pay comparable costs, making the criminalization of homelessness costly to everyone. There have been some efforts to address homelessness through other means, such as providing affordable housing, but dealing with the underlying causes is certainly challenging given existing values.

Once again, trying to solve a problem through criminalization proves to be a terrible approach. Even on the heartless grounds of saving money, it fails—the cost of policing the homeless would seem to consume whatever savings might be accrued for letting people fall through the social safety net. This, of course, could be countered—one might be able to show that the monetary cost strategies aimed at getting the homeless into homes would exceed the cost of policing the homeless on the streets. After all, the politicians could lower the cost significantly simply by not policing the homelessness who do not commit serious crimes, such as robbery. This, however, does still leave the homeless without homes and this can impose other economic costs—such medical expenses paid for by the public. This could be countered by arguing that the homeless should be completely abandoned—this would certainly yield financial savings.

Such abandonment does, however, run into a moral challenge. The harms suffered by the homeless (and society) would seem to make a compelling utilitarian moral argument in favor of approaches that aim at getting the homeless back into society. Moral views that accept that people should love one another also enjoin us to not abandon our fellows. In any case, criminalizing homelessness is no solution, financial or moral.

Drug addiction is another problem that has largely been addressed by criminalization. About half of the people in federal prisons and 16% of those in state prison are there for drug offenses. This is the result of the war on drugs, which endeavored to solve the drug problem by arresting our way out of it. Since the negative consequences of this approach fell mainly on minorities and the poor, there was little interest among politicians to take a different approach. However, as prison populations swelled and public attitudes towards drug use changed, there was some talk of reconsidering this war. The biggest change in the public discussion arose from the opioid epidemic—a drug epidemic that goes beyond ravaging the poor and minorities to impacting the white middle class.  This has resulted in some changes in the approach to the problem, such as the police offering free treatment for drug users rather than arresting them. It does remain to be seen if these changes will be lasting and widespread. However, this is certainly a positive change to a failed approach to the health issue of drugs.

While some for profit prisons have done well for their shareholders in the war on drugs, the financial cost to society as a whole has been substantial. Criminalization of addiction has also failed to reduce addiction. As such, this approach has proven a practical failure.

As above, there are also the moral concerns about this approach in terms of the harms being inflicted on individuals and society as a whole. Fortunately, there is a chance that America will rethink the war on drugs (in which we are the enemy) and recast it as a health issue. This not only has the potential to be far more of a practical success, it also would seem to be the right thing to do morally. Transforming people in need into criminals cannot solve the ills of society; addressing those needs can.

 

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Running Addiction

Posted in Running, Sports/Athletics by Michael LaBossiere on November 7, 2010

Newsweek recently published an article by Steve Tuttle titled “Addicted to a Run.” While the article was mostly about the fact that Steve Brewer has not missed a day of running in 25 years. Tuttle does not mention that there are many other runners who have even longer streaks. I must admit that I’m a slacker now: my streak only lasted a bit over two decades.

Having been a running fanatic, I have wondered if running can be an addiction. I am inclined to say that it can. After all, it can actually start to cause problems in a person’s life in a way that is comparable to recognized addictions. In my own case, I would run even when sick or injured and would give my running and racing priority over almost everything else.  I even ran to the point that running was actually making me less healthy: I was so over-trained that my blood pressure was elevated (but still pretty good for my age) and I felt horrible. I eventually ended my streak and now have a much healthier approach to my healthy approach.

Of course, there are some important differences between running addiction and other addictions. First, running in moderation is very beneficial in many ways. In contrast, moderate drinking might have some minor health benefits and “moderate” heroin use has none at all. Second, running seems to be easier to control than other addictions. True, I was hooked bad on running but was able to just say “I am not running today” and simply did it. Unlike other addictions, it is usually rather hard to get people addicted to running. In fact, it is usually rather hard to get people to run at all. Third, even being addicted to running is usually better than not exercising at all. Even when I was over-trained, I was still in far better shape than non-runners. Fourth, running addiction does not seem to lead to the negative behavior of other addictions: running addicts don’t commit crimes to get more miles, they generally do not become violent, and running generally does not result in divorce or loss of employment. So, as far as addictions go, running is a good choice.

I have heard that some people have used running to avoid other addictions. While I’ve never been addicted to anything else, I do have some anecdotal evidence from fellow runners that seem to support this claim. At the very least, it is hard to stay addicted to tobacco and running at the same time. However, I have known runners who were also alcoholics, so it is clearly not a perfect defense.

My advice: run.

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Are We Addicted to Oil?

Posted in Politics by Michael LaBossiere on July 6, 2010
Addiction (Ryan Leslie song)
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In his recent speech, Obama trotted out the old claim that we need to deal with our oil addiction. This, naturally enough, raises the question of whether we are addicted to oil or not. This hinges on what is meant by the term “addiction.” Rather than get into a hair splitting semantical debate, I will go with an obvious and intuitive account of addiction.

Addiction  “ is characterized by impairment in behavioral control, craving, inability to consistently abstain, and diminished recognition of significant problems with one’s behaviors and interpersonal relationships.”

On the face of it, we do seem to have such an addiction. As a nation, we seem to have a lack of behavior control when it comes to consuming and acquiring oil. We also generally fail to recognize that we have serious behavioral problems relating to oil. We are generally willing to kill and allow our own people to die to ensure access to it. We are also willing to put our health and the environment at risk in order to acquire and use oil. We do this even though their are safer alternatives available that do not involve a need to engage in violent foreign adventures.

Of course, it could be countered that we actually have a legitimate need for oil and our actions reflect this need rather than the pathological behavior of addiction. After all, we do engage in similar behavior to ensure “national security”, yet this would not be characterized as an addiction.

However, given that there are better alternatives to oil, our commitment to it does seem to be increasingly irrational and thus it seems more and more like behavior based in an addiction.  Some might attempt to defend oil by arguing that everyone uses it or that it is a good thing. Interestingly enough, that sort of strategy is used by drug addicts as well.

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