A Philosopher's Blog

Health Care Workers and Moral Objections II: Patients/Clients

Posted in Ethics, Law, Medicine/Health, Philosophy, Politics by Michael LaBossiere on January 24, 2018

As noted in an earlier essay, the Trump administration plans to modify the Health and Human Services (HHS) civil rights office to protect health care workers who have moral or religious objections to performing certain medical procedures or treating certain patients.  In that essay I addressed the general moral issue of  whether health workers have the moral right to refuse certain services. I now turn to the general issue of whether they have the moral right to refuse to treat certain patients (or clients) based on the identity of the patients (or clients). The legal matter, of course, is something for the courts to settle.

As noted in the earlier essay, a person does not surrender their moral rights or conscience when they enter a profession. As such, it should not simply be assumed that a health care worker cannot refuse to treat a person because of the worker’s values. But, of course, it should also not be assumed that the moral or religious values of a health care worker grant them the right to refuse treatment based on the identity of the patient.

One moral argument for the right to refuse treatment because of the patient’s identity is based on the general right to refuse to provide a good or service. A key freedom, one might argue, is this freedom from compulsion. For example, an author has every right to determine who they will and will not write for.

Another moral argument for the right to refuse is a general one about the right to not be forced to interact with people whom one regards as evil or at least immoral. This can also be augmented by contending that serving the needs of an immoral person is to engage in an immoral action, if only by association. For example, a Jewish painter has every right to refuse to paint a mural for Nazis.

While these arguments have considerable appeal, especially in cases in which the refusal is directed at the sorts of people one dislikes, it is important to consider the implications of a right of refusal based on values. One obvious implication is that such a right could warrant a health care worker to refuse to treat you if they regarded you as immoral. In general terms, moral rights need to be assessed by applying a moral method I call reversing the situation. Parents and others often employ this method informally by asking questions such as “how would you feel if someone did that to you?”

Somewhat more formally, this method is based on the Golden Rule: “do unto others as you would have them do unto you.” Assuming this rule is correct, if a person is unwilling to abide by his own principles when the situation is reversed, then it is reasonable to question those principles. In the case at hand, while a person might be fine with the right to refuse services to those they dislike because of their values, they would presumably not be fine with it if the situation were reversed.

An obvious objection is that reversing the situation would, strictly speaking, only apply to health workers themselves. Fortunately, there is a modified version of this method that would apply to everyone. In this method one test of a moral right, principle or rule is for a person to replace the proposed target of the right, principle or rule with themselves or a group (or groups) they belong to. For example, a Christian who thinks it is morally fine to refuse services to transgender people based on religious freedom should consider their thoughts on atheists refusing services to Christians based on religious freedom. Naturally, a person could insist that the right, rule or principle should only be applied to those they do not like—but if anyone can take this out, then it would seem everyone could as well, thus the objection would fail.

One reasonable reply to this method is to point out that there are clear exceptions to its application. For example, while most Christians are fine with convicted murders being locked up, it does that follow that they are wrong about this because they would not want to be locked up for being Christians. In such cases, which also applies to reversing the situation, it can be argued that there is a morally relevant difference between the two people or groups that justifies the difference in treatment. For example, convicted murders generally deserve to be punished for being murders while Christians obviously do not merit punishment just for being Christians. As such, when considering the moral right of health care workers to refuse services based on the identity of the patient (or client) the possibility of relevant differences must be given due consideration.

The obvious problem with relevant difference considerations is that people will tend to think there is a relevant difference between themselves and those they want to apply the right of refusal. For example, a person who is a social justice warrior might regard a member of the alt-right as an evil racist and see this as a relevant difference that warrants refusing service to such a person. One solution is to appeal to an objective moral judge—but this creates the obvious problem of finding such a person. Another solution is for the person to take special pains to be objective—but this is rather difficult and especially so in cases in which objectivity is often most needed.

A final relevant consideration is the fact that while entering a profession does not strip a person of their conscience or moral agency, it often imposes professional ethics on the person that supersede their own values within the professional context. For example, lawyers must accept a professional ethics that requires them to keep certain secrets their client might have (the most obvious being when they did the crime) even when doing so might violate their personal ethics. As another example, lawyers (especially public defenders) are expected to defend their clients even if they find their clients morally awful. As a third example, as a professor I (in general) cannot insist that a student be removed from my class by appealing to my religious or moral values regarding the identity of the student. As a professor, I am obligated to teach anyone enrolled in my class, if they do not engage in behavior that would warrant their removal (such as assaulting other students). Health care workers generally fall under professional ethics as well and these typically include requirements to render care to people regardless of what the worker things of the morality of the person. For example, a doctor does not have the right to refuse to perform surgery on someone just because they committed adultery, are a compulsive liar, have engaged in shady and even illegal business practices or expressed their proclivity to grab people by a certain part of their anatomy. This is not to say that there cannot be exceptions, but professional medical ethics would seem to forbid refusing service just because of the moral judgment by the service provider of the patient (or client). This, obviously enough, is distinct from refusing services because a patient or client has engaged in behavior that warrants refusal, such as attacking the service provider.

 

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Health Workers & Moral Objections I: Procedures

Posted in Ethics, Philosophy, Politics, Religion by Michael LaBossiere on January 19, 2018

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The Trump administration plans to modify the Health and Human Services (HHS) civil rights office to protect health care workers who have moral or religious objections to performing certain medical procedures or treating certain patients. As should be expected, the focus of concern is mainly on abortion and transgender patients. Two of the general moral issues raised by this situation are whether health workers have the moral right to refuse certain services and whether they have the right to refuse to treat certain patients based on the identity of the patients.

While some might, perhaps while thinking of abortion rights, automatically conclude that health care workers have no moral right to refuse services, this would be far to hasty. After all, entering a profession does not entail that a person surrenders their moral rights or conscience. To think otherwise would be to embrace the discredited notion that just following orders or just doing one’s job provides a blanket moral excuse for one’s professional actions. As such, since health care workers are morally accountable for their actions, they also retain the moral agency and freedom needed to ground that accountability.

But, this moral coin has another side—entering a profession, especially in the field of health, also comes with moral and professional responsibilities. These responsibilities can, like all responsibilities, can justly impose burdens. For example, doctors are not permitted to instantly abandon patients they dislike or because they want to move to a better paying position. As such, ethics of a health worker refusing to perform a procedure based on their moral or religious views requires that each procedure be reviewed to determine whether it is one that a health care worker can justly refuse or one that is a justly imposed burden.

To illustrate, consider a doctor who is asked to keep prisoners conscious and alive during torture performed by agents of the state. Most doctors, like most people, would have moral objections to being involved in torture. However, there is the question of whether this would be something they should be morally expected to do as part of their profession. On the face of it, since the purpose of the medical profession is to heal and alleviate suffering (a professional ethics that goes back to the origin of western medicine) this is not something that a doctor is obligated to do even in the face of moral objections. In fact, the ethics of the profession would dictate against engaging in this behavior.

Now, imagine a health care worker who has sincere religious or moral beliefs that when a person can no longer sustain their life on their own, they must be released to God. As such, the worker refuses to engage in procedures that violate their principles, such as keeping a patient on life support. While this could be a sincerely held belief, it seems to run counter to the ethics of the profession. As such, such a health care worker would seem to not have the right to refuse such services.

One could even imagine very extreme cases—after all there is no requirement to prove that sincerely held religious belief is true, one must only be convincing in one’s alleged sincerity. For example, imagine a health care worker who has a sincere religious belief that a patient must prove themselves worthy in the eyes of God by surviving with only the most basic care; anything beyond that is an affront to God’s will: the patient will survive if God wants them to and humans should not interfere with this. Obviously enough, such workers’ views would not be accepted as justifying their actions—they should seek another profession if they cannot do their jobs.

Turning back to services like abortion and gender transition, the issue would be whether these are more like asking a medical worker to participate in torture or more like expecting a medical worker to provide normal medical services. As should be expected, this is a central point of the dispute. Those who oppose abortion will make the moral argument that performing abortion is as bad or worse than abetting torture—it does, after all, involve killing a living entity. Those who are pro-choice will contend that it is a medical procedure like any other. I must admit that I do not have a compelling argument to change any minds on this matter.

In the case of gender transition, there can be no appeal to concerns about killing. Rather, a person must appeal to the view that people should not modify their sex and should simply accept what they were born with. This seems to be more like my imaginary case of a health care worker who believes that people must prove themselves worthy in the eyes of God than like the torture case, especially if someone takes the view that God wants people to stick with their original sex. That said, it could be argued that such modifications are wrong in the same way that non-restorative cosmetic surgery is wrong—after all, both aim to allow a person to be as they envision themselves to be. I do not, however, want to claim that the transitional process is as trivial as a face lift. Once again, I do not think I have a compelling argument here that will change any minds.

While I do not think I will change minds about abortion and such, I do think that the matter of moral objections needs to be given due consideration. It is easy to simply embrace one’s unreflecting views without considering the possibility of error. In my next essay I’ll turn to the issue of whether health workers have the moral right to refuse services based on the identity of the patient, such as their being transgender or Christian.

 

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Patient Time

Posted in Medicine/Health, Uncategorized by Michael LaBossiere on October 20, 2017

A standard to response to criticism of the American health care “system” is that it is the best in the world. In a sense, this is true–if you have the money, you can buy the best health care (mostly). However, the quality of a system is not just a matter of what can be bought at the top. To use an analogy, if a restaurant was considered the best because its most expensive meal was the best, but everything else that most customers could afford was not so good, then it would be odd to consider it the best restaurant for everyone. Naturally, the American “system” could be praised as the best for those who have the resources to afford it, but that would be somewhat dishonest.

One serious issue with health care, at least for those who cannot afford to have their own doctor on call, is the matter of time. For most of us, there is a wait before we can get an appointment, then we wait at the office to see the doctor. This can be problematic for people with schedules that lack flexibility and people who need treatment sooner rather than later. I have good insurance, but it took me two months to get an appointment with a new primary care doctor. Having more medical professionals would reduce these delays, but this is a problem that has not been addressed.

After a long wait, a patient typically gets very little time with the doctor or medical professional. For example, I have usually gotten 10 minutes with my primary doctor or nurse for my physical–I spend far more time in the waiting room. This is not to say that these doctors did not care–they did and did the best they could with the time allocated.

Part of the reason for the short time is that most medical professionals have too many patients and too little time–as such, they can only allocate so much time to each patient. In other cases, the medical facility is a for-profit business first and a place of medicine second–the faster customers can be dealt with, the more customers can be seen, thus increasing profits. Whatever the reason for the short time available to patients, this can certainly impact the quality of care, especially if a patient has questions. Because of this, patients are often on their own in terms of educating themselves about their health concerns. Obviously, having people with no medical training doing this can be problematic (and it helps explain the huge market for dubious supplements and remedies).

Since part of the problem is the need for more medical professionals, steps should be taken to encourage and enable more people to enter the field. Since part of the problem is the for-profit approach, this should be addressed–while it is often assumed that the purpose of life is to make money, applying this to medicine results in worse rather than better health care. This is not to say that medical professionals should not be generously compensated for their work, just that the for-profit business model of medicine needs to be modified. At the very least.

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The High Price of Being Shot

Posted in Ethics, Law, Philosophy, Politics by Michael LaBossiere on October 11, 2017
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In the naivety of my youth, I believed that people would not be charged for medical treatment resulting from being wounded by criminals. After all, my younger self reasoned, their injuries were the fault of someone else and it would be unjust to expect them to pay for the misdeeds of another. Learning that this was not the case was just one of the many disappointments when it came to the matter of justice and ethics. As such, I was not surprised when I learned that shooting victims were presented with the bills for their treatment. However, I was somewhat surprised by the high cost of being shot.

Dr. Joseph Sakran, who had been shot in his youth, co-authored a study of what shooting victims are charged for their treatment. Since gunshot wounds range from relatively minor grazing wounds to massive internal damage, the costs vary considerably. While the average is $5,000 the cost can go up to $100,000. These costs are generally covered by insurance, but victims who lack proper coverage become victims once again: they must either pay for the treatment or pass on the cost as part of the uncompensated care. When the cost is passed on, the patient can suffer from severely damaged credit and, of course, the cost is passed on others in the form of premium increases. There can be costs beyond the initial medical bills, such as ongoing medical bills, the loss of income, and the psychological harm.

In addition to medical expenses of those who are shot, there are also the costs of the police response, the impact on employers, and the dollar value of those who are killed rather than wounded (and do not forget that dying in the hospital obviously does not automatically clear the bill). While estimating the exact cost is difficult, a mass shooting like the Pulse Nightclub shooting will probably end up costing almost $400 million. While mass shootings, such as the recent one in Las Vegas, get the attention of the media, gunshot wounds are a regular occurrence in the United States with an estimated cost of $600 million per day. While some will dispute the exact numbers, what is indisputable is that getting shot is expensive for the victim and society. As such, it would be rational to try to reduce the number of shootings and to address the high cost of being shot.

While the rational approach to such a massive health crisis would be to undertake a scientific study to find solutions, the 1996 Dickey Amendment bans the use of federal funding for gun research. There is also very little good data about gun injuries and deaths—and this is quite intentional. Efforts to improve the collection of data are dealt with by such things as the Dickey Amendment. Efforts to impose more gun control, even when there is overwhelming public support for such things as universal background checks, are routinely blocked. While this serves as a beautiful object lesson in how much say the people have in this democracy, it also shows that trying to address the high cost of getting shot by reducing shootings is a noble fool’s errand. As such, the only practical options involve finding ways to offset the medical costs of victims. Naturally, victims can bring civil suits—but this is not a reliable and effective way to ensure that the medical expenses are covered. After all, mass shooters are rarely wealthy enough to pay all the bills and often perish in their attack.

Some victims have attempted to address their medical bills in the same way others who lack insurance have tried—by setting up GoFundMe pages to get donations. While this option is problematic in many ways, the main problem is that it is not very reliable. This, of course, lays aside the moral problem of having people begging so they can pay for being victims of a shooting. To address this problem, I will make two modest proposals.

My first proposal is that gun owners be required to purchase a modestly priced insurance policy that is analogous to vehicle insurance. In the United States, people are generally required to have insurance to cover the damage they might inflict while operating a dangerous piece of machinery. This helps pool the risk (as insurance is supposed to do) and puts the cost on the operators of the machines rather than on those who they might harm. The same should apply to guns—they are dangerous machines that can do considerable harm and it makes sense that the owners should bear the cost of the insurance. Naturally, as with vehicles, owners can also be victims.

It could be objected that owning a firearm is a right and hence the state has no right to impose such a requirement. The easy and obvious reply is that the right to keep and bear arms is a negative right rather than a positive right. A positive right is one in which a person is entitled to be provided with the means to use that right (such as how people are provided with free ballots when they go to vote). A negative right means the person must provide the means of exercising their right, but it is (generally) wrong to prevent them from exercising that right. So, just as the state is not required to ensure that people get free guns and ammunition, it is not required to allow gun ownership without insurance—provided that the requirement does not impose an unreasonable infringement on the right.

Another easy and obvious reply is that rights do not free a person from responsibility. In the case of speech, people cannot simply say anything without consequence. In the case of the gun insurance, people would be acting in a responsible manner—they would be balancing their right with a rational amount of responsibility. To refuse to have such insurance is to insist on rights without responsibility—something conservatives normally rail against. As such, both liberals and conservatives should approve of this idea.

My second proposal, which is consistent with the first, is that there be a modest state fee added to the cost of each firearm, accessory and ammunition box. This money would go into a state pool to help pay the medical expenses of the uninsured who are injured in shootings. Yes, I know that this money would probably be misused by most states, probably to bankroll the re-election of incumbents. The justification is, of course, that the people who buy the guns that could hurt people should bear the cost for the medical expenses of those who are hurt. People already pay sales taxes on such items, this would merely earmark some money to help offset the cost of people exercising their second amendment rights. To go back to the vehicle analogy, it makes perfect sense to add a fee onto the cost of gas to pay for roads and other infrastructure—that way the people who are using it are helping to pay for it. Likewise for guns.

An obvious objection is that this fee would be paid by people who will never engage in gun crime. This is a reasonable concern, analogous to other concerns about paying into anything that one is not directly responsible for. There are two reasonable replies. One is that the funds generated could cover medical expenses involving any firearm crime or accident and anyone can have an accident with a gun. Another is the responsibility argument: while I, as a gun owner, will probably never engage in a gun crime, being able to exercise my right to own guns allows people who will engage in gun crimes to engage in those crimes. For example, the Las Vegas shooter was operating under the protection of the same gun rights that protect me up until the moment he started firing. This fee would be my share of the responsibility for allowing the threat of gun violence to endanger everyone in the United States. Such a modest fee would be a very small price to pay for having such a dangerous right. Otherwise, I would be selfishly expecting everyone else to bear the cost of my right, which would not be right. So, to appeal to principled conservatives, this would be a way for taking responsibility for one’s rights. As people love to say, freedom isn’t free.

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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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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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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
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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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