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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