A Philosopher's Blog

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

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

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

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

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

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

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

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

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

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

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

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


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Why Runners are not Masochists (Usually)

Posted in Ethics, Philosophy, Running, Sports/Athletics by Michael LaBossiere on February 10, 2014

Palace 5KAs a runner, I am often accused of being a masochist or at least having masochistic tendencies. Given that I routinely subject myself to pain and recently wrote an essay about running and freedom that was rather pain focused, this is hardly surprising. Other runners, especially those masochistic ultra-marathon runners, are also commonly accused of masochism.

In some cases, the accusation is made in jest or at least not seriously. That is, the person making it is not actually claiming that runners derive pleasure (perhaps even sexual gratification) their pain. What seems to be going on is merely the observation that runners do things that clearly hurt and that make little sense to many folks. However, some folks do regard runners as masochists in the strict sense of the term. Being a runner and a philosopher, I find this a bit interesting—especially when I am the one being accused of being a masochist.

It is worth noting that I claim that people accuse runners of being masochists with some seriousness. While some people say runners are masochists in jest or with some respect for the toughness of runners, it is sometimes presented as an actual accusation: that there is something mentally wrong with runners and that when they run they are engaged in deviant behavior. While runners do like to joke about being odd and different, I think we generally prefer to not be seen as actually mentally ill or as engaging in deviant behavior. After all, that would indicate that we are doing something wrong—which I believe is (usually) not the case. Based on my experience over years of running and meeting thousands of runners, I think that runners are generally not masochists.

Given that runners engage in some rather painful activities (such as speed work and racing marathons) and that they often just run on despite injuries, it is tempting to believe that runners are really masochists and that I am in denial about the deviant nature of runners.

While this does have some appeal, it rests on a confusion about masochism in regards to matters of means and ends. For the masochist, pain is a means to the end of pleasure. That is, the masochist does not seek pain for the sake of pain, but seeks pain to achieve pleasure. However, there is a special connection between the means of pain and the end of pleasure: for the masochist, the pleasure generated specifically by pain is the pleasure that is desired. While a masochist can get pleasure by other means (such as drugs or cake), it is the desire for pleasure caused by pain that defines the masochist. As such, the pain is not an optional matter—mere pleasure is not the end, but pleasure caused by pain.

This is rather different from those who endure pain as part of achieving an end, be that end pleasure or some other end. For those who endure pain to achieve an end, the pain can be seen as part of the means or, perhaps more accurately, as an effect of the means. It is valuing the end that causes the person to endure the pain to achieve the end—the pain is not sought out as being the “proper cause” of the end. In the case of the masochist, the pain is not endured to achieve an end—it is the “proper cause” of the end, which is pleasure.

In the case of running, runners typically regard pain as something to be endured as part of the process of achieving the desired ends, such as fitness or victory. However, runners generally prefer to avoid pain when they can. For example, while I will endure pain to run a good race, I prefer running well with as little pain as possible. To use an analogy, a person will put up with the unpleasant aspects of a job in order to make money—but they would certainly prefer to have as little unpleasantness as possible. After all, she is in it for the money, not the unpleasant experiences of work. Likewise, a runner is typically running for some other end (or ends) than hurting herself.  It just so happens that achieving that end (or ends) requires doing things that cause pain.

In my essay on running and freedom, I described how I endured the pain in my leg while running the Tallahassee Half Marathon. If I were a masochist, experiencing pleasure by means of that pain would have been my primary end. However, my primary end was to run the half marathon well and the pain was actually an obstacle to that end. As such, I would have been glad to have had a painless start and I was pleased when the pain diminished. I enjoy the running and I do actually enjoy overcoming pain, but I do not enjoy the pain itself—hence the aspirin and Icy Hot in my medicine cabinet.

While I cannot speak for all runners, my experience has been that runners do not run for pain, they run despite the pain. Thus, we are not masochists. We might, however, show some poor judgment when it comes to pain and injury—but that is another matter.

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Is the Emergency Room a Viable Alternative?

Posted in Ethics, Law, Medicine/Health, Philosophy by Michael LaBossiere on August 30, 2013
Typical scene at a local emergency room

 (Photo credit: Wikipedia)

As Obamacare marches onward, its opponents are still endeavoring to stop its advance and send it packing. Of course, the opponents need to provide an alternative system. Interestingly, certain Republicans such as Rick Perry and Jim DeMint have claimed that uninsured Americans are better off relying on the emergency room for treatment. While the battle over Obamacare is largely ideological, the viability of using the emergency room would seem to be an objective matter.

On the positive side, anyone can go to the emergency room and hospitals cannot refuse to treat people with legitimate medical needs—even people who lack insurance or cannot pay.

However, there are numerous problems with the uninsured (or even the insured) relying on the emergency room. The first is the matter of cost. The emergency room is generally more expensive than the non-emergency options. It is certainly more expensive that routine preventative care that can keep a person out of the emergency room. The high costs are problematic because of the burden on the uninsured (medical bills is a leading cause of bankruptcy in America) and also because when the uninsured cannot pay, the cost is passed on to the rest of us (most often in the form of higher health insurance premiums). Thus, relying on the emergency room to treat the uninsured places a heavy burden on everyone and is actually a form of highly inefficient socialism in which those with insurance pay for needlessly expensive treatment for the uninsured. From a purely economic standpoint, if we are going to have medical socialism, we should at least go with the more economically efficient version.

The second is the matter of preventative medicine and ongoing treatments, such as routine checkups and dialysis. The emergency room hardly seems to be set for these medical matters, although people who are unable to avail themselves of them stand a significant chance of ending up in the emergency room, thus taking us back to the first problem. As such, the emergency room option does not seem to be a viable alternative to Obamacare. This is not to say that Obamacare is the only option or even a good option—just that it is better than the emergency-room-for-the-uninsured option.

The third is the matter of compassion. While hospitals cannot deny people necessary medical care, such care is certainly not charity: either the patient must pay or the cost is passed on to the rest of us. As such, relying on the emergency room as a matter of social policy is essentially saying to people that they can get treatment, provided that it is an emergency and that either the patient can pay or the cost can be passed on to everyone else. It is generally agreed that we should collectively protect each other from terrorism, foreign enemies, and our own criminals. This same concern should also extend to protecting each other from disease and injury. After all, whether Sally is dead because of cancer, a criminal’s bullet or a terrorist’s bomb, she is still dead. So, if we can have a huge collective defense against these other threats, we surely can have a developed collective defense against medical threats—one that is better than the emergency room.


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Pain, Pills & Will

Posted in Ethics, Medicine/Health, Philosophy, Politics, Science, Sports/Athletics by Michael LaBossiere on January 4, 2013
A Pain That I'm Used To

(Photo credit: Wikipedia)

There are many ways to die, but the public concern tends to focus on whatever is illuminated in the media spotlight. 2012 saw considerable focus on guns and some modest attention on a somewhat unexpected and perhaps ironic killer, namely pain medication. In the United States, about 20,000 people die each year (about one every 19 minutes) due to pain medication. This typically occurs from what is called “stacking”: a person will take multiple pain medications and sometimes add alcohol to the mix resulting in death. While some people might elect to use this as a method of suicide, most of the deaths appear to be accidental—that is, the person had no intention of ending his life.

The number of deaths is so high in part because of the volume of painkillers being consumed in the United States. Americans consume 80% of the world’s painkillers and the consumption jumped 600% from 1997 to 2007. Of course, one rather important matter is the reasons why there is such an excessive consumption of pain pills.

One reason is that doctors have been complicit in the increased use of pain medications. While there have been some efforts to cut back on prescribing pain medication, medical professionals were generally willing to write prescriptions for pain medication even in cases when such medicine was not medically necessary. This is similar to the over-prescribing of antibiotics that has come back to haunt us with drug resistant strains of bacteria. In some cases doctors no doubt simply prescribed the drugs to appease patients. In other cases profit was perhaps a motive. Fortunately, there have been serious efforts to address this matter in the medical community.

A second reason is that pharmaceutical companies did a good job selling their pain medications and encouraged doctors to prescribe them and patients to use them. While the industry had no intention of killing its customers, the pushing of pain medication has had that effect.

Of course, the doctors and pharmaceutical companies do not bear the main blame. While the companies supplied the product and the doctors provided the prescriptions, the patients had to want the drugs and use the drugs in order for this problem to reach the level of an epidemic.

The main causal factor would seem to be that the American attitude towards pain changed and resulted in the above mentioned 600% increase in the consumption of pain killers. In the past, Americans seemed more willing to tolerate pain and less willing to use heavy duty pain medications to treat relatively minor pains. These attitudes changed and now Americans are generally less willing to tolerate pain and more willing to turn to prescription pain killers. I regard this as a moral failing on the part of Americans.

As an athlete, I am no stranger to pain. I have suffered the usual assortment of injuries that go along with being a competitive runner and a martial artist. I also received some advanced education in pain when a fall tore my quadriceps tendon. As might be imagined, I have received numerous prescriptions for pain medication. However, I have used pain medications incredibly sparingly and if I do get a prescription filled, I usually end up properly disposing of the vast majority of the medication. I do admit that I did make use of pain medication when recovering from my tendon tear—the surgery involved a seven inch incision in my leg that cut down until the tendon was exposed. The doctor had to retrieve the tendon, drill holes through my knee cap to re-attach the tendon and then close the incision. As might be imagined, this was a source of considerable pain. However, I only used the pain medicine when I needed to sleep at night—I found that the pain tended to keep me awake at first. Some people did ask me if I had any problem resisting the lure of the pain medication (and a few people, jokingly I hope, asked for my extras). I had no trouble at all. Naturally, given that so many people are abusing pain medication, I did wonder about the differences between myself and my fellows who are hooked on pain medication—sometimes to the point of death.

A key part of the explanation is my system of values. When I was a kid, I was rather weak in regards to pain. I infer this is true of most people. However, my father and others endeavored to teach me that a boy should be tough in the face of pain. When I started running, I learned a lot about pain (I first started running in basketball shoes and got huge, bleeding blisters). My main lesson was that an athlete did not let pain defeat him and certainly did not let down the team just because something hurt. When I started martial arts, I learned a lot more about pain and how to endure it. This training instilled me with the belief that one should endure pain and that to give in to it would be dishonorable and wrong. This also includes the idea that the use of painkillers is undesirable. This was balanced by the accompanying belief, namely that a person should not needlessly injure his body. As might be suspected, I learned to distinguish between mere pain and actual damage occurring to my body.

Of course, the above just explains why I believe what I do—it does not serve to provide a moral argument for enduring pain and resisting the abuse of pain medication. What is wanted are reasons to think that my view is morally commendable and that the alternative is to be condemned. Not surprisingly, I will turn to Aristotle here.

Following Aristotle, one becomes better able to endure pain by habituation. In my case, running and martial arts built my tolerance for pain, allowing me to handle the pain ever more effectively, both mentally and physically. Because of this, when I fell from my roof and tore my quadriceps tendon, I was able to drive myself to the doctor—I had one working leg, which is all I needed. This ability to endure pain also serves me well in lesser situations, such as racing, enduring committee meetings and grading papers.

This, of course, provides a practical reason to learn to endure pain—a person is much more capable of facing problems involving pain when she is properly trained in the matter. Someone who lacks this training and ability will be at a disadvantage when facing situations involving pain and this could prove harmful or even fatal. Naturally, a person who relies on pain medication to deal with pain will not be training themselves to endure. Rather, she will be training herself to give in to pain and become dependent on medication that will become increasingly ineffective. In fact, some people end up becoming even more sensitive to pain because of their pain medication.

From a moral standpoint, a person who does not learn to endure pain properly and instead turns unnecessarily to pain medication is doing harm to himself and this can even lead to an untimely death. Naturally, as Aristotle would argue, there is also an excess when it comes to dealing with pain: a person who forces herself to endure pain beyond her limits or when doing so causes actually damage is not acting wisely or virtuously, but self-destructively. This can be used in a utilitarian argument to establish the wrongness of relying on pain medication unnecessarily as well as the wrongness of enduring pain stupidly. Obviously, it can also be used in the context of virtue theory: a person who turns to medication too quickly is defective in terms of deficiency; one who harms herself by suffering beyond the point of reason is defective in terms of excess.

Currently, Americans are, in general, suffering from a moral deficiency in regards to the matter of pain tolerance and it is killing us at an alarming rate. As might be suspected, there have been attempts to address the matter through laws and regulations regarding pain medication prescriptions. This supplies people with a will surrogate—if a person cannot get pain medication, then she will have to endure the pain. Of course, people are rather adept at getting drugs illegally and hence such laws and regulations are of limited effectiveness.

What is also needed is a change in values. As noted above, Americans are generally less willing to tolerate even minor pains and are generally willing to turn towards powerful pain medication. Since this was not always the case, it seems clear that this could be changed via proper training and values. What people need is, as discussed in an earlier essay, training of the will to endure pain that should be endured and resist the easy fix of medication.

In closing, I am obligated to add that there are cases in which the use of pain medication is legitimate. After all, the body and will are not limitless in their capacities and there are times when pain should be killed rather than endured. Obvious cases include severe injuries and illnesses. The challenge then, is sorting out what pain should be endured and what should not. Since I am a crazy runner, I tend to err on the side of enduring pain—sometimes foolishly so. As such, I would probably not be the best person to address this matter.

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Primary Care

Posted in Medicine/Health by Michael LaBossiere on July 13, 2011
A patient having his blood pressure taken by a...

Image via Wikipedia

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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Do I Envy the Rich?

Posted in Business, Ethics, Philosophy by Michael LaBossiere on March 14, 2011
The Seven Deadly Sins (ca. 1620) - Envy

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Because I have written some posts critical of the current economic system I have been accused of envy and jealousy.

Like most people, I do not think of myself as being envious. However, I could be wrong about this. As such, I’ll take the time to consider this charge.

The charge of jealousy can be easily dismissed. Strictly speaking, jealousy is based on a fear of loss to another. Since I do not fear that I will lose what little I have to the rich, I am not jealous of them. However, the charge of envy requires a bit more work.

To start my rely, I need a definition of “envy.” Since I am a philosopher, I’ll consider two definitions put forth by better thinkers than I. Aristotle regarded envy “as the pain caused by the good fortune of others.” Kant, ever the wordy fellow, took it to be “a reluctance to see our own well-being overshadowed by another’s because the standard we use to see how well off we are is not the intrinsic worth of our own well-being but how it compares with that of others.”

For the sake of brevity, I’ll go with Aristotle’s definition.

As far as I can tell, the good fortune of those who are rich does not cause me any pain. My writings also do not seem to show that I feel pain at such good fortune. In fact, years of athletic competition have taught me to think well of those who succeed through just means in difficult endeavors. I have run with (or rather far behind) elite athletes and do not feel any pain at their success. Rather, I am impressed with their talent and training and wish them well. I would, of course, like to be as good as they are and this does cause me some pain-namely the pain of working those hills and doing what I rather dislike: running round and round a track as fast as a I can.

As far as I can tell, I feel the same about the rich who have earned their wealth through fair means and in the face of challenges. Artists, writers, athletes, inventors, business folks and so on who have started from little (or nothing) and have earned top spots in the income brackets have not my envy, but my respect and admiration. Those who started with much, but have done great things also are not victims of any envy on my part. As with running, people who are out ahead of me via hard work and just efforts only motivate me.

I am, of course, critical of what strikes me as unfair, unjust, harmful, unethical or otherwise bad. To stick with the running analogy, if I criticize a runner who wins by using performance enhancing chemicals that are banned, I hardly seem to be envious. A better explanation, given my established character, is that I am against such cheating. Likewise, if I am critical of some aspect of the economic system that involves deceit, bribery, law breaking, or something that is harmful to the general good, then it seems most reasonable to attribute my motivation to being concerned about matters of ethics and justice rather than to accuse me of the base motivation of envy.

It might be wondered what would count as evidence of envy. Could I not be hiding bitter envy behind a cloak of alleged virtue?

That is, of course, a reasonable challenge. After all, who would admit to being motivated by envy, prejudice, greed or other such base emotions? Do we not all dress up our ugly emotions in finery so that the appear things of beauty and loveliness?

Of course we do. It would be an error to think otherwise. However, it is also an error to assume that what lies behind someone you disagree with is a base emotion as a motivation. To assume that I am critical of economic injustices because I am secretly enraged by my lack of a yacht, mansions, billions and bling would equally be an error. This would be on par with assuming that a person is against taxes because he is motivated merely by greed or that someone is pro-defense because she is motivated by a lust for bloodshed.

To fairly accuse someone of such a base motivation would require adequate evidence.

One rather decisive indicator of envy would require that I become rich. If my behavior and writing did not change, then it would seem odd to attribute what I do to envy. After all, I would have no reason to be envious then. Of course, as I am not devoted to becoming rich, this shall only happen by chance and thus is rather unlikely.

A less clear indicator is, of course, the content what I actually write and my behavior. One can go through it and look for signs that I feel pain at the good fortune of the rich. For example, if I merely lashed out at the rich without any foundation beyond my wanting their money and not having it, then that would provide some evidence. If, however, I were to present considered arguments and take into account opposing views, then it would be rather hard to take that as evidence of envy-unless, of course, any criticism of anything counts as envy.

As another example, if I were regularly engaged in activities that were clearly aimed at being rich or otherwise showed clear signs that what I truly valued was being rich, then there would be at least some foundation for a claim of envy. Since my chosen profession is professor of philosophy and my other interests are not money focused (running, gaming, writing unpaid blogs, and so on) it would seem odd to claim that I am money focused. While I am no genius, I did very well in college and was able to get a PhD from Ohio State. As such, I think it is reasonable to infer that I could have been a success in another far more lucrative field if money was, in fact, my consuming focus. As far as the stock charge that professors are only professor because they could not hack it outside of the ivory tower, the burden of proof is on those who make the charge. In any case, anyone who knows me well knows that I could hack it just fine.

Of course, what would also be needed is evidence that I  feel pain at my lack of adequate success in money making endeavors and this pain is caused by the success of others (and not merely the pain of failure). That evidence also seems to be sorely lacking.

As such, I would infer that I am not envious of the rich. I am, however, critical of certain practices, laws and individuals. Naturally, I am open to evidence that I am deluding myself, that I am, in fact, full of repressed envy of the rich.

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The Steak Analogy

Posted in Business, Ethics, Medicine/Health, Philosophy by Michael LaBossiere on August 23, 2010
Steak and chips
Image via Wikipedia

A few days ago I saw a segment on CNN about how some hospitals overcharge patients. For example, a hospital might charge over $100 for a single Tylenol or charge a patient four times the price of a surgical instrument. What struck me as most interesting in the segment was that an administrator defended the practice with an analogy.

He compared going to the hospital to getting a nice steak dinner. As he pointed out, a nice steak restaurant charges the customer far more than it would cost the customer to buy a steak at the supermarket and prepare it at home.  Assuming that a steak dinner and a trip to the hospital are analogous, then the hospital would also be justified in charging the customer considerably more than what it would cost the customer to buy an instrument or pill.

At first glance, the analogy seems reasonable. After all, when you go to a restaurant you pay more because you are getting more. To be specific, they prepare and serve the steak. Likewise, the hospital does not just sell you a pill or instrument-they use it as part of a treatment process. Just as it makes sense to pay for the preparation of the steak, it makes sense to pay more for the service the hospital provides.

However, a closer examination shows that the analogy breaks. When you buy a steak at a restaurant, the price of the steak includes the preparation, service and the setting (that is you are sort of renting a table by buying a meal). As such, the meal is more expensive than an uncooked steak you buy at the market because you are actually getting more than just an uncooked steak. While the restaurant breaks the bill down to include what you order, they do not break down the costs into ingredients, preparation and so on.

In the case of the hospital, the patient is charged “item by item.” To be specific, the hospital bill lists the charge for each service, each instrument, each unit of medicine and so on. So, when a patient is charged four times the cost of an instrument or $100 for a Tylenol that charge does not include the services. It just includes the cost of the item in question. For the analogy to the steak dinner to work, restaurants would have to bill customers for each ingredient at a very steep markup and then tag on charges for all the services and so on that the restaurant provided. For example, a steak that would sell for $15 at the supermarket might cost $60. Naturally, the customer would also be charged for the cooking, the electricity used, the arrangement of the food on the plate, the silverware cleaning, and so on. In this case, the price charged for the steak itself would be unfair. After all, the customer is paying four times the cost of the steak itself and merely getting the steak for that price. Everything else is extra. Likewise for the medical markup.

While it is fair to pay for the services that the hospital provides in addition to the cost of the medicine and such used in the treatment, it is unfair to have to pay for a huge markup on such things. After all, the patient is not getting anything in return for the excessive charge.

The analogy also breaks down in other ways. For example, eating at a nice steak restaurant is a luxury while medical service is often a necessity. Charging excessively for necessities is different from charging a lot for luxuries. As another example, people can easily prepare a steak at home to save money, so going to a restaurant is a matter of choice. In most cases, people cannot provide medical treatment at home (for example, home surgery is not really an option).  To charge people excessively because they have no real alternative is quite different from charging people much more for a nice steak. As such, the comparison to a steak dinner at a restaurant fails in significant ways.

Of course, the folks who defend such charges also have another argument: hospitals need to make money to stay in business. If they did not make enough money, the hospital would not be there the next time someone needed it.

This does, of course, justify hospitals charging for their goods and services. After all, they need money to buy equipment and supplies and to pay employees. However, this argument does not justify charging excessive amounts of money for supplies and medicines. A steak analogy can be used here.

Suppose you go to a restaurant and get charged $500 for your steak dinner. You complain and ask why it costs so much. The manager says that $60 of it was for the cost of the steak and the remainder is for various services, ingredients and expenses. When you point out that they paid $15 for the steak, the manager says that if you did not pay the markup, there would be no restaurant here the next time you were hungry. Obviously, you would not be convinced that the bill was justified. The restaurant could easily stay in business and make a profit by charging much less. Presumably the same is true of hospitals.

Of course, it might be replied that a hospital needs to charge so excessively to stay in business. However, this does not work as a reply. Suppose, for example, that a forceps costs the hospital $200 (including shipping, processing and so on) and they charge the patient $800 for it.  Of course, they also charge for everything else as well, so the $800 is just for the $200 forceps. In terms of staying in business, a $200 charge for the forceps would be enough since the patient also pays for everything else as well. If, however, the patient is being charged $800 for the forceps to pay for other goods and services, then the hospital should simply put those costs on the bill. After all, they are quite adept at listing everything else, right down to the last Tylenol.  As such, charging such excessive fees is not justified by the “staying in business” argument.

It could also be replied that the hospital needs to make a profit. After all, the business of business is not to treat patients or provide affordable care, it is to make a profit. Obviously, the key to profit is to charge the customer for more than he is actually getting. After all, if the fee charged merely equals the cost of the materials, services, administration, and so on, then there would be no profit. While there are some excellent arguments that profit is thus by its very nature unjust, let it be assumed that people have a right to profit. Of course, the question then arises as to the just limits of profit. In the case of medical bills, they often seem to exceed these just limits. After all, unlike steak dinners, medical treatment is often not an optional luxury, but a necessity.

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Viagra For Women

Posted in Medicine/Health, Philosophy by Michael LaBossiere on May 25, 2010
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Well, not quite. However, a drug that is supposed to boost a woman’s libido is being considered for approval by the FDA. This drug, flibanserin, is supposed to have three positive effects: 1) increase in sexual desire, 2) greater sexual satisfaction, and 3) a reduction in emotional distress. Roughly put, it promises better sex through chemistry.

Since men who suffer from erectile dysfunction have various erection corrections to chose from, it seems only fair that women have a similar opportunity to rectify their sexual problems. Given the delay in the development of comparable drugs for women, it might be suspected that old attitudes about female sexuality were a factor. After all, the old stereotypes are that while men are always interested in sex, it is natural for women to lack sexual desire and to merely endure sex without experiencing pleasure. As such, one might claim, a lack of sexual desire and pleasure are not conditions that need correction but merely the natural state for women. Of course, research seems to show that this is not the case and thus the drug would seem to be addressing real problems.

Rather than get into a debate about the true nature of female sexuality, I will instead address the matter of medication. If the drug is addressing a medical problem, then it seems reasonable for women who have that problem to use the drug. This would be analogous to the situation of men who medically need Viagra and to the situation of people who need blood pressure medication.

However, the drug might also be used in cases in which the conditions it is supposed to address are caused by factors that the drug itself does not correct. For example, if a woman is not experiencing desire because of stress or a poor relationship, the drug will merely cover up those problems with a chemically created pseudo-desire. As another example, if a woman is not enjoying sex because she and her partner are not doing a very good job, then the drug will merely cover up that problem as well. As a final example, if a woman is feeling distressed because of real problems, then the drug will merely mask the feelings without doing anything to solve the problems.

It might be replied that even in such cases the drug would be a real improvement because it would enhance the woman’s quality of life: she would feel more desire, more pleasure and less distress. Surely, one might argue, that would justify using the medicine?

That is, of course, a reasonable point. After all, when I take aspirin because of a running injury, it does not help heal the injury. It merely reduces the pain. But, of course, taking the aspirin is fine. That is, provided that masking the pain does not interfere with addressing the underlying cause of the pain.  If it does, then the aspirin will actually contribute to making things worse. An even better analogy might be alcohol: it is said that alcohol can help with sexual desire-but that is hardly a desirable solution.

Likewise for the drug-if a woman medicates herself and does not address the underlying problems, then these problems will remain unresolved. They would either tend to remain the same or even grow worse, perhaps requiring more or new drugs. As such, it would be more sensible to address the underlying problems rather than masking them.

Another reply might be that this criticism would seem to be yet another example of sexual stereotyping. After all, why single out this drug for criticism?

This is a reasonable concern and would be a serious objection if my view were limited to this drug. However, my view of this drug is based on a general principle about drugs, namely that masking problems using drugs is not a wise approach. This is not to say that I am opposed to drugs. But, I think that we have created an unfortunate approach to medication and health issues that has been partially fueled by the pharmaceutical companies. To be specific, there is a general tendency to over-medicate.

In the case of this specific drug, I have no issue with women who have a legitimate medical need for treatment. However, I think it would be a poor choice to use this drug without first determining the cause of the problems and the possibility of addressing them. While I am no expect on female libido, I suspect that in many cases the cause is not a medical disorder but a life problem (the relationship, work, stress, and so on). While a drug might address the effects of life problems, it would not address the causes.

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Fetal Pain

Posted in Ethics by Michael LaBossiere on April 2, 2010
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The state of Nebraska has added a (seemingly) new phrase to the abortion debate, namely “fetal pain.” The gist of the view is that abortions after twenty weeks should not be allowed on the grounds that the fetus might feel what is happening to it.

While it is not known exactly when a fetus can feel pain, the Journal of the American Medical Association asserts that it is unlikely that the fetus feels pain prior to twenty eight weeks. The question of when a fetus has sufficient neurological development that would allow it to experience pain would certainly seem to be an empirical matter. Of course, the situation can be made more complicated by bringing in metaphysical concerns about when the fetus has a mind that can actually experience pain and suffer from such pain (there might be an important distinction between feeling pain and suffering from pain).

Determining when the fetus can feel and suffer from such pain does seem important. After all, many moral arguments are based on the capacity of beings to experience pain. For example, stock arguments in the moral debate over the treatment of animals rest on the fact that many of the ways we treat animals (such as how we raise them as food) causes them pain and suffering.

If the pain and suffering of animals matters morally, then it would certainly seem that the pain and suffering of fetuses would also matter morally. In fact, many of the arguments for not harming or mistreating animals based on their capacity to feel pain could be modified slightly to serve as arguments against harming fetuses that can feel pain.

Of course, this means that objections raised against pain/suffering based arguments in the case of animals could often be modified for use against the pain/suffering based arguments regarding fetuses.

On a logically irrelevant note, this could mean that folks who are pro-choice but against animal suffering might find their own arguments against mistreating animals re-purposed to argue against abortions. Likewise, folks who are anti-abortion but argue for the moral acceptability of (mis)using animals might find their arguments for allowing animal suffering to be re-purposed and used against their anti-abortion views.

Getting back to the main discussion , it does seem that pain and suffering are morally relevant. Intuitively, this makes sense. To steal an approach from Hume, simply think of your own pain and suffering and see if you can regard these as good things. It is also easy enough to take advantage of numerous existing arguments for pain and suffering having negative moral value (Mill is the obvious choice here). Naturally, there are also good arguments against this, but it hardly seem foolish to consider that inflicting pain and suffering tends to be morally wrong.

If this is granted, then abortions that cause pain and suffering to the fetus would certainly seem to have a morally negative element well worth considering. However, this would hardly be a morally decisive point. After all, the mere fact that something causes pain and suffering does not automatically make it wrong or unacceptable. One reason for this is that pain and suffering are typically taken as having relative rather than absolute weight. In other words, pain and suffering on the part of one party is usually weighed against positive value or against the pain and suffering of another party. For example, when arguing about animal testing in the context of medicine, the pain of the animals is typically matched against the gain to be had from the medicine.

In the case of abortion, the pain and suffering of the fetus would be weighed against other factors, such as the pain and suffering of the woman. This is, of course, old moral ground that has been debated extensively. In many cases the suffering the woman (or girl) would undergo would far outweigh the pain and suffering of the fetus, thus allowing the abortion to occur. If someone argued that the fetus has an absolute right not to suffer or feel pain, then the obvious counter is to inquire why the same would not apply to the woman as well and why such a clash between absolutes should be settled in favor of the fetus. After all, the burden of proof would seem to rest on those who claim an unborn and unfinished being has a greater moral status than a person.

I suspect that the main result of the introduction of “fetal pain” into the legal battle will not be a significant change in the ethical debate. Rather, the main impact will be that a (seemingly) new rhetorical tool (or weapon, depending on your view) is now available.

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