A Philosopher's Blog

Philosophical Essays on Many Subjects

health care

Maternal Mortality

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Among developed countries, the United States is the leader in maternal mortality. This is, unfortunately, the wrong kind of leadership—the mortality rate has been increasing. Fortunately, infant mortality in the United States is relatively low.

One reason for the higher mortality rate is that women are giving birth at an older age than in the past, thus increasing the likelihood of complications and death. In general, women seem to be waiting on families because of economic concerns. This is yet another way in which economic injustice and instability literally kills people. As such, one way to address the mortality rate is crafting an economy that is more just and more stable—something the Republicans seem to vehemently oppose and Democrats seem incapable of doing.

While there is a significant political push against birth control, health care and reproductive clinics, another reason deaths have increased is that many pregnancies are unplanned, so women do not have the opportunity to address health issues before getting pregnant. One part of the solution is to improve family planning availability; although the push is for reducing such access. Another part of the solutions falls on individuals—they should take better care of themselves. Not just for cases of pregnancy, but in general. While people often want the state to legislate solutions, personal responsibility is a critical part of addressing this problem.

A third factor is that C-sections have increased. While some note that some doctors and hospitals like C-sections because they can schedule them, there is a variety of other reasons for the increase. While C-sections are necessary in some cases, in other cases they increase the health risks for the mother and baby. As such, the efforts to reduce the number of unnecessary C-sections should increase. One major obstacle is composed of the various economic factors that contribute to the number of unnecessary C-Sections, these could prove difficult to address in the context of profit-driven health care.

A fourth factor, which contributes to general poor health outcomes across the population, is that the United States health system is highly fragmented and compartmentalized. As such, new mothers can face health threatening challenges when they try to navigate this system. While there have been efforts to create a more unified health system, the trend does not look promising. Tied into this factor is the other general issue of affordable health care. As Trump and the Republicans promised, they are working hard to dismantle the existing system but seem to have little interest in addressing the problems that Obamacare tried to plaster over. Since the solution would be a well-designed health care system, it seems unlikely that this aspect of the problem will be solved in the foreseeable future. Unless the Republicans decide to take positive steps or the Democrats win enough seats to implement a viable plan.

In closing, it should be noted that while health care for the general population is a low priority for the current administration and most Republicans; the health care of women is an even lower priority. In fact, the main political focus has been on the issue of abortion and holding such clinics hostage with the threat of cutting federal funding.

 

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Health Care Workers and Moral Objections II: Patients/Clients

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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

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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

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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.

The High Price of Being Shot

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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)

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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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