A Philosopher's Blog

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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The Corruption of Academic Science

Posted in Ethics, Philosophy, Science, Universities & Colleges by Michael LaBossiere on November 5, 2014
Synthetic insulin crystals synthesized using r...

Synthetic insulin crystals synthesized using recombinant DNA technology (Photo credit: Wikipedia)

STEM (Science, Technology, Engineering and Mathematics) fields are supposed to be the new darlings of the academy, so I was slightly surprised when I heard an NPR piece on how researchers are struggling for funding. After all, even the politicians devoted to cutting education funding have spoken glowingly of STEM. My own university recently split the venerable College of Arts & Sciences, presumably to allow more money to flow to STEM without risking that professors in the soft sciences and the humanities might inadvertently get some of the cash. As such I was somewhat curious about this problem, but mostly attributed it to a side-effect of the general trend of defunding public education. Then I read “Bad Science” by Llewellyn Hinkes-Jones. This article was originally published in issue 14, 2014 of Jacobin Magazine. I will focus on the ethical aspects of the matters Hinkes-Jones discussed in this article, which is centered on the Bayh-Dole Act.

The Bayh-Dole Act was passed in 1980 and was presented as having very laudable goals. Before the act was passed, universities were limited in regards to what they could do with the fruits of their scientific research. After the act was passes, schools could sell their patents or engage in exclusive licensing deals with private companies (that is, monopolies on the patents). Supporters asserted this act would be beneficial in three main ways. The first is that it would secure more private funding for universities because corporations would provide money in return for the patents or exclusive licenses. The second is that it would bring the power of the profit motive to public research: since researchers and schools could profit, they would be more motivated to engage in research. The third is that the private sector would be motivated to implement the research in the form of profitable products.

On the face of it, the act was a great success. Researchers at Columbia University patented the process of DNA cotransfrormation and added millions to the coffers of the school. A patent on recombinant DNA earned Stanford over $200 million. Companies, in turn, profited greatly. For example, researchers at the University of Utah created Myriad Genetics and took ownership of their patent on the BRCA1 and BRCA2 tests for breast cancer. The current cost of the test is $4,000 (in comparison a full sequencing of human DNA costs $1,000) and the company has a monopoly on the test.

Given these apparent benefits, it is easy enough to advance a utilitarian argument in favor of the act and its consequences. After all, if allows universities to fund their research and corporations to make profits, then its benefits would seem to be considerable, thus making it morally good. However, a proper calculation requires considering the harmful consequences of the act.

The first harm is that the current situation imposes a triple cost on the public. One cost is that the taxpayers fund the schools that conduct the research. The next is that thanks to the monopolies on patents the taxpayers have to pay whatever prices the companies wish to charge, such as the $4,000 for a test that should cost far less. In an actual free market there would be competition and lower prices—but what we have is a state controlled and regulated market. Ironically, those who are often crying the loudest against government regulation and for the value of competition are quite silent on this point.  The final cost of the three is that the corporations can typically write off their contributions on their taxes, thus leaving other taxpayers to pick up their slack. These costs seem to be clear harms and do much to offset the benefits—at least when looked at from the perspective of the whole society and not just focusing on those reaping the benefits.

The second harm is that, ironically, this system makes research more expensive. Since processes, strains of bacteria and many other things needed for research are protected by monopolistic patents the researchers who do not hold these patents have to pay to use them. The costs are usually quite high, so while the patent holders benefit, research in general suffers. In order to pay for these things, researchers need more funding, thus either imposing more cost on taxpayers or forcing them to turn to private funding (which will typically result in more monopolistic patents).

The third harm is the corruption of researchers. Researchers are literally paid to put their names on positive journal articles that advance the interests of corporations. They are also paid to promote drugs and other products while presenting themselves as researchers rather than paid promoters. If the researchers are not simply bought, the money is clearly a biasing factor. Since we are depending on these researchers to inform the public and policy makers about these products, this is clearly a problem and presents a clear danger to the public good.

A fourth harm is that even the honest researchers who have not been bought are under great pressure to produce “sexy science” that will attract grants and funding. While it has always been “publish or perish” in modern academics, the competition is even fiercer in the sciences now. As such, researchers are under great pressure to crank out publications. The effect has been rather negative as evidenced by the fact that the percentage of scientific articles retracted for fraud is ten times what it was in 1975. Once lauded studies and theories, such as those driving the pushing of antioxidants and omega-3, have been shown to be riddled with inaccuracies.  Far from driving advances in science, the act has served as an engine of corruption, fraud and bad science. This would be bad enough, but there is also the impact on a misled and misinformed public. I must admit that I fell for the antioxidant and omega-3 “research”—I modified my diet to include more antioxidants and omega-3. While this bad science does get debunked, the debunking takes a long time and most people never hear about it. For example, how many people know that the antioxidant and omega-3 “research” is flawed and how many still pop omega-3 “fish oil pills” and drink “antioxidant teas”?

A fifth harm is that universities have rushed to cash in on the research, driven by the success of the research schools that have managed to score with profitable patents. However, setting up research labs aimed at creating million dollar patents is incredibly expensive. In most cases the investment will not yield the hoped for returns, thus leaving many schools with considerable expenses and little revenue.

To help lower costs, schools have turned to employing adjuncts to do the teaching and research, thus creating a situation in which highly educated but very low-paid professionals are toiling away to secure millions for the star researchers, the administrators and their corporate benefactors. It is, in effect, sweat-shop science.

This also shows another dark side to the push for STEM: as the number of STEM graduates increase, the value of the degrees will decrease and wages for the workers will continue to fall. This is great for the elite, but terrible for those hoping that a STEM degree will mean a good job and a bright future.

These harms would seem to outweigh the alleged benefits of the act, thus indicating it is morally wrong. Naturally, it can be countered that the costs are worth it. After all, one might argue, the incredible advances in science since 1980 have been driven by the profit motive and this has been beneficial overall. Without the profit motive, the research might have been conducted, but most of the discoveries would have been left on the shelves. The easy and obvious response is to point to all the advances that occurred due to public university research prior to 1980 as well as the research that began before then and came to fruition.

While solving this problem is a complex matter, there seem to be some easy and obvious steps. The first would be to restore public funding of state schools. In the past, the publicly funded universities drove America’s worldwide dominance in research and helped fuel massive economic growth while also contributing to the public good. The second would be replacing the Bayh-Dole Act with an act that would allow universities to benefit from the research, but prevent the licensing monopolies that have proven so damaging. Naturally, this would not eliminate patents but would restore competition to what is supposed to be a competitive free market by eliminating the creation of monopolies from public university research. The folks who complain about the state regulating business and who praise the competitive free market will surely get behind this proposal.

It might also be objected that the inability to profit massively from research will be a disincentive. The easy and obvious reply is that people conduct research and teach with great passion for very little financial compensation. The folks that run universities and corporations know this—after all, they pay such people very little yet still often get exceptional work. True, there are some people who are solely motivated by profit—but those are typically the folks who are making the massive profit rather than doing the actual research and work that makes it all possible.

 

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Medbots, Autodocs & Telemedicine

Posted in Ethics, Medicine/Health, Philosophy, Technology by Michael LaBossiere on October 27, 2014

In science fiction stories, movies and games automated medical services are quite common. Some take the form of autodocs—essentially an autonomous robotic pod that treats the patient within its confines. Medbots, as distinct from the autodoc, are robots that do not enclose the patient, but do their work in a way similar to a traditional doctor or medic. There are also non-robotic options using remote-controlled machines—this would be an advanced form of telemedicine in which the patient can actually be treated remotely. Naturally, robots can be built that can be switched from robotic (autonomous) to remote controlled mode. For example, a medbot might gather data about the patient and then a human doctor might take control to diagnose and treat the patient.

One of the main and morally commendable reasons to create medical robots and telemedicine capabilities is to provide treatment to people in areas that do not have enough human medical professionals. For example, a medical specialist who lives in the United States could diagnose and treat patients in a remote part of the world using a suitable machine. With such machines, a patient could (in theory) have access to any medical professional in the world and this would certainly change medicine. True medical robots would obviously change medicine—after all, a medical robot would never get tired and such robots could, in theory, be sent all over the world to provide medical care. There is, of course, the usual concern about the impact of technology on jobs—if a robot can replace medical personnel and do so in a way that increases profits, that will certainly happen. While robots would certainly excel at programmable surgery and similar tasks, it will certainly be quite some time before robots are advanced enough to replace human medical professionals on a large scale

Another excellent reason to create medical robots and telemedicine capabilities has been made clear by the Ebola outbreak: medical personnel, paramedics and body handlers can be infected. While protective gear and protocols do exist, the gear is cumbersome, flawed and hot and people often fail to properly follow the protocols. While many people are moral heroes and put themselves at risk to treat the ill and bury the dead, there are no doubt people who are deterred by the very real possibility of a horrible death. Medical robots and telemedicine seem ideal for handling such cases.

First, human diseases cannot infect machines: a robot cannot get Ebola. So, a doctor using telemedicine to treat Ebola patients would be at not risk. This lack of risk would presumably increase the number of people willing to treat such diseases and also lower the impact of such diseases on medical professionals. That is, far fewer would die trying to treat people.

Second, while a machine can be contaminated, decontaminating a properly designed medical robot or telemedicine machine would be much easier than disinfecting a human being. After all, a sealed machine could be completely hosed down by another machine without concerns about it being poisoned, etc. While numerous patients might be exposed to a machine, machines do not go home—so a contaminated machine would not spread a disease like an infected or contaminated human would.

Third, medical machines could be sent, even air-dropped, into remote and isolated areas that lack doctors yet are often the starting points of diseases. This would allow a rapid response that would help the people there and also help stop a disease before it makes its way into heavily populated areas. While some doctors and medical professionals are willing to be dropped into isolated areas, there are no doubt many more who would be willing to remotely operate a medical machine that has been dropped into a remote area suffering from a deadly disease.

There are, of course, some concerns about the medical machines, be they medbots, autodocs or telemedicine devices.

One is that such medical machines might be so expensive that it would be cost prohibitive to use them in situations in which they would be ideal (namely in isolated or impoverished areas). While politicians and pundits often talk about human life being priceless, human life is rather often given a price and one that is quite low. So, the challenge would be to develop medical machines that are effective yet inexpensive enough that they would be deployed where they would be needed.

Another is that there might be a psychological impact on the patient. When patients who have been treated by medical personal in hazard suits speak about their experiences, they often remark on the lack of human contact. If a machine is treating the patient, even one remotely operated by a person, there will be a lack of human contact. But, the harm done to the patient would presumably be outweighed by the vastly lowered risk of the disease spreading. Also, machines could be designed to provide more in the way of human interaction—for example, a telemedicine machine could have a screen that allows the patient to see the doctor’s face and talk to her.

A third concern is that such machines could malfunction or be intentionally interfered with. For example, someone might “hack” into a telemedicine device as an act of terrorism. While it might be wondered why someone would do this, it seems to be a general rule that if someone can do something evil, then someone will do something evil. As such, these devices would need to be safeguarded. While no device will be perfect, it would certainly be wise to consider possible problems ahead of time—although the usual process is to have something horrible occur and then fix it. Or at least talk about fixing it.

In sum, the recent Ebola outbreak has shown the importance of developing effective medical machines that can enable treatment while taking medical and other personnel out of harm’s way.

 

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Protect Life Act

Posted in Ethics, Law, Medicine/Health, Philosophy, Politics by Michael LaBossiere on October 16, 2011
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Abortion is a matter of seemingly endless moral and political debate. In the latest round, the Republican controlled House has passed the Protect Life Act. Two of the main aspects of the act include preventing federal money from being used in health care plans that cover abortion and to allow health care workers to refuse to perform abortions. This includes cases in which an abortion is medically necessary to save a woman’s life.

The first aspect of the act seems to be at least partially a solution in search of a problem. The Affordable Care Act (known by the dysphemism “Obamacare”) already prevents public money separate from private insurance payments covering abortion. However, the is a common misconception (intentionally fueled) that “Obamacare” pays for abortions.

The act goes beyond this in an attempt to restrict coverage of abortion. The bill, if made into a law, would forbid women from buying private insurance plans including abortion coverage. This is, of course, limited to purchases made through a state health care exchange.

The main justification for this aspect of the bill is that the Republican backers claim that taxpayer dollars should not go to abortions. Of course, the bill goes beyond that and attempts to restrict women’s choices.

On the face of it, the justification has a certain appeal. After all, in a democratic (or republican) system, the taxpayers have a right to decide where their tax dollars are spent (and also to have a role in decisions in general-if only via representatives). As such, if the majority of Americans are opposed to having tax dollars go to abortion, then it would be presumably correct to not provide such funding. Majority rule and all that would serve as the moral justification. This would, of course, entail that the same principle should apply uniformly. So, for example, if the citizens did not want subsidies going to corporations or did not want to fun capital punishment, then such things should not be allowed.

In the case of abortion, most Americans hold that it should be legal. While this does not entail that they want to fund abortions, it would seem to indicate that abortion rights are accepted by the majority of Americans. As such, attempting to restrict these rights under the guise of keeping taxpayer money from funding abortion would seem to be somewhat deceptive. After all, it is one thing to prevent public money from being used and it is quite another to forbid women from buying private insurance with their own money. It is especially ironic given the Republican mantras about the free market and individual choice.

Also, if most Americans favor the legality of abortion and the Republican backers of the bill are claiming that they are right to impose restrictions based on the fact that some people are morally opposed to abortion, then it would seem to follow that anything that is morally opposed should not be funded. This would include capital punishment, war, the drug war and so on. In fact, it seems likely that very little would be left with public funding. Naturally, it could be argued that the moral opposition would need to be significant, but even under that condition capital punishment and many other things could no longer be funded with public money. Perhaps this would be a good thing-but I am reasonable sure that neither the Democrats nor the Republicans would be willing to accept this a general principle.

Perhaps the most controversial component of the bill is that health care workers who morally oppose abortion will have the legal right to refuse to perform abortions-even when doing so is medically necessary to prevent the death of the woman. Currently hospitals are legally required to perform abortions when doing so is medically necessary to saving the life of the woman.  Some Catholic hospitals have been breaking the existing law for years.

On the one hand, a strong case can be made for allowing health care workers to decline performing an abortion on moral grounds. After all, a law that compels people to perform what they regard as an immoral action (such as fighting in war or paying taxes to support a war or what they regard as an unjust system) would seem to be well worth both moral and legal scrutiny. This matter has, of course, been addressed in regards to civil disobedience and the question of what a person should do when his/her conscience conflicts with the laws of the state.

In the case of non-emergency procedures, I am certainly sympathetic to the view that health care workers with strong moral beliefs should not be forced to engage in what they regard as an immoral action (most likely murder). Likewise, I am sympathetic to people who refuse to fight in war or support the state on the grounds that they regard the killing  (or murder) of human beings as immoral.

On the other hand, a strong case can be made that professionals are obligated to perform their jobs even when doing so goes against their conscience. For example, a nurse who is opposed to drug use would not seem to have the right to refuse to treat a victim of a self-inflicted drug overdose of illegal drugs. As another example, a police officer who thinks that homosexuality is an abomination would not seem to have the right to refuse to protect a homosexual who is being beaten to death.

In the case of emergency procedures, a very strong case can be made that such procedures should be performed. On utilitarian grounds, performing such procedures would seem to be right. After all, the most likely result of not performing the procedure is that the woman and the fetus both die. The procedure would at least save the life of one person, which would presumably be a good action. To use an analogy, imagine that a child has been rigged with a terrorist bomb and is running at a woman. The bomb cannot be removed in time and will detonate in seconds. A soldier or police officer is nearby and can stop the child-but only by shooting her. The woman can, of course, scream to the soldier/officer that she would rather die with her child. However, it would not seem wicked of the soldier or officer to take the shot if the woman did not forbid it.

It can, of course, be argued that this is not a utilitarian matter but a matter of the action itself being right or wrong. If it is assumed that abortion is wrong because it is killing, it would seem to follow that not helping the woman would also be wrong-after all, this would cause her death.

At this point it is natural to bring up the stock distinction between killing and letting die. In the case of the woman, the medical care provider would be letting her die rather than killing the other being (which may or may not be a person). In general, our moral intuitions tend to indicate that killing is worse than letting die, which could be taken as a point in favor of allowing health care providers to let women die rather than perform an abortion. However, since the being will also die anyway (in most cases) it would seem that refusing to save the woman would (as noted above) merely double the number of deaths rather than do something that would be morally commendable. This could even be argued on the same moral basis as triage. In this case, the act could be seen not as killing the being, but saving the mother rather than allowing two patients to die. To use an analogy, if a mother and child were brought to a hospital and both were dying and the doctor knew that her choice was between saving the mother or letting both die while she worked to futilely save the child, then the right thing to do would seem to be to save the mother. Expending pointless effort on a child that could not be saved while letting the mother die would not be noble or good. Rather it would be a wrongful decision that would kill the mother.  As such, this provision is clearly immoral.

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Republican Battle Circle

Posted in Politics by Michael LaBossiere on September 29, 2011
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The Republican presidential candidates face the standard double challenge of the out party. On the one hand, each of the candidates faces the challenge of overcoming his/her rivals and becoming the actual presidential candidate. On the other hand, the contenders need to (or should) be concerned about the nature of the in-party fighting. After all, each attack launched on a fellow candidate can provide the rival party with one more piece of ammunition to use in the actual election.  It can also cause strains within the party, making it harder to pull together for the election. Of course, if a candidate goes too easy or does not return fire when attacked by a fellow candidate, then they can be perceived as a weak candidate.

This challenge is somewhat like what a team faces while sorting out who will be varsity and who will be junior varsity. If they compete too hard among themselves, then they can end up injured and do poorly when it comes to actual competition with other teams. However, if they do not compete enough, then sorting out the division will be rather difficult.

While such infighting has occurred in the past, this year seems especially harsh. First, this is no doubt partially due to the fact that politics seems even more negative and contentious than in recent years and this has become a way of operating even within the party.

Second, there is also the fact that the pool of candidates is rather large, which might lead the candidates to compete even more fiercely to stand out and to stake out their own territory.

Third, there is faction factor. The Republican party contains the Tea Party and various other very active groups (such as the various social conservatives) and the candidates need to pander to these groups and their ideology in order to succeed. These groups seem to be often defined by what they do not like (taxes, gays, immigration, health care, and so on). Hence appealing to them typically involves taking a strong (or even extreme) position against what the groups in question do not like. However, specific candidates often need to hold positions contrary to one (or more) of these groups in order to do well (for example) in their current office. For example, Perry has taken shots regarding the matter of illegal aliens. Bashing another candidate on this matter is thus very appealing in that it appeals to the group in question, it can weaken the opponent, and it can enable the attacker to stand out. One obvious problem with this approach has been that the in-party bashing and pandering to the various factions has led the various factions to disagree with each other in regards to the candidates. This creates something of a problem for the Republican candidates since there is no candidate who has yet been able to gain the approval of the majority of the factions. This will, no doubt, be settled by the party insiders at the appropriate time. However, it would be interesting to see a candidate or two decide to strike out on their own after being rejected by the Republican party.

A final point of concern is that the more that a candidate tries to win over the more extreme factions, the worse the candidate will probably do in the general election. After all, the Republicans cannot win just be getting the Republican votes. They need the independents and perhaps even some Democrats.

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Primary Care

Posted in Medicine/Health by Michael LaBossiere on July 13, 2011
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One specific health care problem is the shortage of primary care physicians. There are various reasons why fewer people are deciding to be primary care physicians, but the one that is most often cited is the matter of money. While a primary care physician can make a good living, their income will generally be less than a specialist. Of course, it is not just a matter of money: some people decide to be specialists because of the challenge, out of personal interest in the area, or out of pride. But money seems to be a rather important factor.

There have been various attempts and proposals to address this matter. One approach is to increase the number of primary care physicians by providing financial incentives, such as support during medical school in return for a period of community service. There have been even better financial deals proposed, but the basic idea behind them all is increasing the number of physicians via the use of government subsidies. On the plus side, this would result in an increase in the number of such doctors (but the exact impact is still unclear). On the minus side, the money has to come from the tax payers (or China).

Another suggested approach is to allow nurses and other medical professionals who are not doctors step into the role of providing such care. In many cases, this sort of things is already being done to a degree. For example, when I had my quadriceps tendon repaired, almost all my follow up was with nurses and physician assistants.  On the plus side, it is easier (and cheaper) to train people for these roles relative to what it costs to train a full doctor. Also, there would presumably be a larger pool of people willing and able to fill these roles.  There is also the fact that much of the needed care does not actually require the training or skills of an actual doctor. As such, this could be a practical way to fill in the gaps in medical care. On the minus side, there is the concern that while such people could fill in many gaps, there would still be important gaps left unfilled that would still require an actual doctor.  However, it seems likely that could addressed as well.

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Mystery Patients

Posted in Ethics, Medicine/Health, Politics by Michael LaBossiere on July 3, 2011
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While many people still dream of becoming (or marrying) doctors, there is a shortage of primary care doctors. Folks in government are concerned about this and one of the most recent proposals is to have people pose as patients in order to determine the difficulty of getting care. One critical part of this is to determine if doctors are rejecting patients who belong to government health programs in favor of the more lucrative private insurance patients. This is, obviously enough, based on the mystery shopper model.

One obvious concern about this method is that it can be seen as a form of spying and also as a deception. While such deceit is acceptable in law enforcement and intelligence operations, this is justified by the fact that the targets are potential (or actual) criminals and enemies. However, the doctors are not suspected of acting illegally and hence the use of this method seems to be questionable.

A second obvious concern is that the money used in this program could be better spent in making positive contributions to health care-such as providing support for doctors willing to provide primary care services for people who are in government programs or in other ways. It is already well established that we need more primary care doctors and it seems almost equally obvious that doctors prefer patients who have private insurance.  This is, of course, due to the main factor of money. In a free market system in which the main goal is to maximize profits, doctors have little incentive to pursue the lower paying career paths or to accept patients on government assistance. As such, there seems little reason to conduct a secret survey in order to learn what already seems to be known.

However, there is certainly merit in investigating the problems that motivated the mystery patient plan. However, this is something that should be done openly rather than with mystery patients.

While it would be nice of people to go through medical school and run their business solely to help people, that sort of devotion to others certainly cannot be expected of people. As such, the most plausible solutions involve providing financial incentives. This can be done by increasing support for medical school students in return for a service commitment and also making the government payouts more appealing to doctors who have money on their minds.

 

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The Boston Sugar Party?

Posted in Ethics, Law, Politics by Michael LaBossiere on April 11, 2011
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Boston, famous for its beans and tea party, is once again in the news. Mayor Tom Menino has signed an executive order that forbids  the sale, promotion and advertising of sugary drinks on government property. The city has six months to comply.

The main justification for this order is that sugary drinks contribute to obesity and obesity is a major health threat in terms of impairing the health of individuals and increasing the cost of medical care. As such, the mayor is acting to protect citizens from the dual harms of obesity: ill health and greater costs.

It is, of course, important to note that the ban is not a general ban. People can still buy all the sugary drinks they desire and advertising can continue urging people to swill until they achieve and awesomely bloated state.  They simply cannot do these things on government property. As such, the impact of this order will probably be a bit limited.

While there are clearly grounds for concern that the ban was the result of an executive order rather than being put to a vote, it can be argued that this ban is justified.

First, there is the harm argument. The main function of government is to protect citizens from harm and this can reasonable taken to include things that have an impact on the physical health of the citizen. So, just as the government can ban dangerous substances from food, it can also legitimately ban sugary drinks on the grounds that they harm the health of citizens.

Of course, the ban is not complete-it just, as noted above, applies to government property. As such, the impact on health will probably be fairly minimal.

Second, there is the economic argument. Cutting government spending is supposed to be the will of the people these days and one way to reduce this spending is to reduce government spending on health care. Obese people are considerably more expensive to care for than people who are not obese. Sugary drinks are packed with empty calories and contribute to obesity. Hence, banning them would presumably help reduce obesity and hence medical costs-most relevantly those taken care of by Medicare and Medicaid.

However, the limited scope of the ban means that the impact on medical costs will probably be fairly minimal (even when the scope is limited to Boston).

Third, there is  the symbolic argument. While the ban will probably have a fairly minor impact on health and savings, it does make a statement and is attracting attention. The city is also engaged in an education program (well, some signs) that are aimed at encouraging people to make better choices about beverages. This might have some impact on peoples’ behavior and lead them to consume fewer sugary beverages.

There are, obviously enough, some reasonable arguments against the ban.

The first is that the ban, as argued above, will probably have little or no meaningful impact. As such, there seems little compelling reason to impose such a ban.

The second, and most important, is that such a ban would seem to infringe on  freedom of choice. While sugary drinks are a very poor choice in terms of health, there does not appear to be adequate  grounds for such a ban, even one limited to government property. Obviously, such drinks are not (yet) illegal to consume and imposing such a ban seems to lack an adequate foundation.

As a general rule, the legitimate ground on which the state can restrict freedom of choice is to prevent harms from being inflicted on others. What would thus have to be shown is that the harm of the drinks outweighs the harm done by placing such restrictions.While it has been claimed that the drinks can make people fat, that is true of any food. True, sugary drinks do provide a great deal of empty calories. However, they do not seem to have special properties that make them especially dangerous and hence fit for a special ban. Their consumption also does not harm others around the consumer (unlike tobacco smoke). Also, anything that has calories can, by its very nature, make people fat. Banning all food and drink that provide calories from government property would, of course, be absurd.

My view is that while people should avoid sugary drinks, this is not a choice that should be made by the state. I do agree that the state should educate people about matters of health and that healthier alternatives should be available and encouraged. But, people have a fundamental right to make poor choices, be it in what sort of beverage they drink or what candidate they vote for.

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