While pharmaceutical companies profited from flooding America with opioids, this inflicted terrible costs on others. Among the costs has been the terrible impact on health. One example of this is endocarditis.

Endocarditis is an abscess on a heart valve. While not limited to drug users, it can be caused by injecting opioids. As opioids were pushed onto the American people, it is no surprise that the number of drug users suffering from endocarditis increased significantly.  The treatment of endocarditis involves a very expensive surgery and many drug users getting this surgery are on Medicaid. To make matters worse, people often return to opioid use after the surgery and this can lead to another expensive surgery, paid for by Medicaid. This raises moral concerns.

There is the moral issue of whether Medicaid should even 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 regarding 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, if the state should provide Medicaid, then the issue of whether the state should pay for endocarditis surgery for opioid addicts arises. It is to this discussion that I now turn.

While it is harsh to argue against paying for an addict’s heart surgery, a moral case can be made in favor of this position. The most obvious way to do this is on utilitarian grounds. As noted above, surgery for endocarditis is very expensive and uses financial and medical resources that could be used elsewhere. If more good could be done by using these resources elsewhere, the utilitarian conclusion is that this is what should be done. This argument can be strengthened by including the fact that addicts often return to 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 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 like the moral justification for triage.

Another approach, which is even harsher, is to focus on the fact that the addicts are giving themselves endocarditis and sometimes 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 no 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 many 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). If this principle is applied to addicts, it must be applied to all cases of self-inflicted harm. While some might take this as a refutation of this view, others might accept this as reasonable and warranting a state of nature approach to medicine in which everyone is on their own.

Another argument can be built around the idea that while there could be an obligation to help people, this obligation is limited. In this case, if a person is treated and knowingly returns to the same harmful behavior, 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 and is surprised when the scoops hit the ground, then it would be reasonable for the parents to buy the child another cone. If the child swings the new cone around and the scoops hit the ground, 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 behavior that caused the harm. They are not morally responsible because they cannot do otherwise. This does have some appeal but would seem to justify requiring addicts to also 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 it could be argued that 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 takes steps to stop doing this.

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 medical care. This approach could be noble or, perhaps, foolish.