Category: Health

Anyone familiar with sports knows that if team members don’t work together, things will go badly. So good athletes set aside internal conflicts when on the field and come together to win. This does not mean that an athlete should accept anything a teammate might do without complaint. For example, a good athlete would not allow a teammate to cheat or a coach to abuse athletes. As another example, a good athlete would not tolerate a teammate committing domestic violence or engage in dog fighting. While we belong to various competing teams, such as nations, during a pandemic we should all be on the same team since we are playing a deadly game of humans versus pathogens.

Since we should be on the same team during a pandemic, we should set aside our differences and work towards victory. If we fight, bicker and compete against each other, we are hurting the team. If we cooperate, we will help Team Human. As with sports, the more power a person has, the more important it is that they work with the team and set aside less important concerns at least for the duration of the game. While it would be unreasonable to think everyone will be a good team player, there is still the expectation that team members will not try to cause needless conflict or interfere with the effort to win. Unfortunately for the world, there will be people who are bad at being team players, and even some who will actively  cause harm during the next pandemic.

While there are examples outside of the United States, I am an American and have some responsibility for my leaders and fellow citizens. During the last pandemic, Trump was president and can be seen as the head coach of the team America. He should have directed the team to victory, inspired the players and done his job properly.

As noted in other essays, rather than being honest about the facts of the pandemic, Trump and his allies downplayed it and then floated stories about hoaxes. Rather than listen to medical experts, Trump and his fellows spread disinformation and misinformation. Trump and his fellows also delayed our response to the virus, something that cost us dearly. What Trump and his fellows should have done is play for Team Human.  To use an analogy, Trump was like a coach who refused to acknowledge that an opposing team was even on the field. Like a bad coach, Trump insisted his team would not need to practice and prepare, that it would be an easy win. And he lied to the team.

During the pandemic, Trump was consistently Trump.  First, he  engaged in conflicts with governors. Part of the problem was that Trump saw himself as making business deals rather than being the leader of a country in crisis. Another part of the problem is that Trump apparently cannot avoid petty fights. He takes things very personally, something that has generally not been true about other American presidents. For example, while Bush was criticized about his handling of Katrina, Bush did not withhold help because  governors failed to appease his ego. To continue the team analogy, Trump was a like a coach who retaliates against the assistant coaches if they  do not appease his ego. Criticism, however legitimate, was met with hostility and punished. This actively harmed the team.

It could be objected that the governors were also to blame. They had a responsibility to work with his flaws to get what their state needed. So, if the governor of NY needed to praise Trump to keep him from vindictively denying the state full assistance, then he must praise Trump. While this makes pragmatic sense, it is morally horrific. In a democratic country it is not the duty of governors or citizens to appease the ego of the president to get them to do their job. It is the duty of the president to do their job, even in the face of criticism. That is how a responsible government is supposed to work. If a leader cannot step up and do the job, they should step aside. Going back to the team analogy, if a narcissistic coach is damaging the team, the solution is not for the assistant coaches to work harder to appease his ego. The solution is to get a new coach.

Second, Trump advanced the conspiracy theory that medical professionals are stealing protective equipment, citing an unnamed distributor who (allegedly) claimed that the hospital was buying too much equipment for its needs. Pushing this conspiracy theory was damaging. Trump  likes conspiracy theories and often used them to shift blame from himself. But this does the team no good. Going back to the analogy, this would be like the head coach falsely accusing team trainers of stealing supplies and blaming them for his failure to ensure that the supplies would be available for the big game.

Trump supporters might, at this point, accuse me of hypocrisy: “How can you speak of unity while criticizing Trump?” The first reply is from basic logic: even if I were a hypocrite, this would not refute my claims. To think otherwise would be to fall victim to the ad hominem tu quoque. One version of this fallacy involves concluding that because a person’s actions are inconsistent with their claim, their claim must be wrong. But this is bad logic. For example, suppose that Bill claimed adultery is wrong and then committed adultery. This would show that he was a hypocrite but would not disprove his claim.

The second reply is that my view is that we should have critical unity. This is not uncritical unity in which people are expected to just go along with whatever the leaders say and do. Uncritical unity can be worse than a lack of unity. For example, imagine if everyone simply went along with Trump’s initial claims about the virus and no one ever pushed back against his misinformation and disinformation. Things would have been much worse. As another example, imagine that during the next pandemic a “radical leftist” state government legally seized  the property of the rich to distribute the resources to help people survive. Trump supporters would obviously not respond by saying “well, we must unite behind our leaders” and go along with this.

The critical part of critical unity in a crisis does need to have limits. The criticism should be grounded in truth, based in principle and aimed at addressing real problems. Criticizing Trump’s disinformation, misinformation, conspiracy theories, and so on while urging unity is critical unity. I apply the same standards across the political spectrum. So, for example, if a Democratic leader spreads pandemic disinformation or refuses to do their job because they are spatting with a Republican, then I would be critical of them. I will also be supportive across the spectrum when leaders are stepping up and doing the best they can. For example, I disagreed with Ohio Governor Mike DeWine on some things (although we both went to college in Ohio) but I credited him for his serious response to COVID-19.

The lesson here is that we need to have unity in times of crisis (which is obvious), but it would be unwise to have unthinking and uncritical unity (which is equally obvious). While we should work with our leaders, they need to prove worthy of our uniting under their leadership. Trump served as paradigm example of how a leader can actively divide rather than unify in a time of crisis. If he or a similar person (be they a Democrat or Republican) is president during the next pandemic, we can expect things to go just as badly.

As COVID-19 ravaged humanity, xenophobia and racism remained alive and well. For example, an Iranian leader  played on fears of America and Israel. He advanced, without evidence, the claim that the virus was created specifically to target Iranians. In addition to conspiracy theories that the Chinese engineered the virus (either to reduce their own population or for use against other nations) there was also a worldwide rise in xenophobia and racism against Asians.

One reason for the xenophobia and racism is that people were looking for a visible enemy upon which to take out their fear and anger. Many people felt helpless and afraid during the pandemic and as humans are inclined to focus on other humans as threats, there was a rise in xenophobia and racism. People are also inclined to seek an intelligence behind dangers, as they did when they attributed natural disasters to gods. Since humans suffer from in group bias and evil leaders feed xenophobia and racism, it is no surprise that people are sought a scapegoat for the  crisis: someone must be to blame. Someone must pay.

The United States, with a long tradition of racism against Asians, saw an increase in xenophobia and racism. While most incidents were limited to verbal hostility, racism in the context of disease raises serious concerns. The United States has a history of weaponizing racism in the context of diseases and we should be on guard against this, because leaders try to appeal to their base and divert attention away from their failings. An example of an American leader’s effort to use xenophobia and racism is Donald Trump using the term “Chinese virus” in place of “coronavirus” or “COVID-19.”

Trump did have excellent, albeit evil, reasons to use these terms. One is that it appeals to parts of his base. This dog whistle sends the message he is speaking to them.  A second reason is that it shifted blame from Trump’s inept and harmful early handling of the pandemic. By presenting it as a Chinese virus Trump created the appearance the threat is the responsibility of a foreign power (and people) and attempted to mitigate his responsibility. Third, it helped create an “us versus them” mentality, with the “them” being other people rather than the virus. Unfortunately, while Trump gained some apparent advantages from this approach, it came with a high cost.

There are those who will defend Trump and take issue with my criticism of him. My first response is that Trump is just an example for the problem of xenophobia and racism. If a Trump defender claims he was not engaged in any racism or xenophobia, then I would refer to the United States being blamed by other for the virus. I suspect a Trump supporter would agree that the xenophobia of other countries towards the United States was not helpful and was, in fact, detrimental.

My second response is that Trump engaged in in open racism and xenophobia. He used the well-worn xenophobic and racist trope of the foreign disease and the diseased foreigner—which was also used in the racism aimed at the allegedly diseased caravans heading towards the United States from the south. That Trump’s defenders had to engage in relentless efforts to explain away his seemingly racist claims undercuts their own case. One would have needed to argue Trump unintentionally but constantly used racist tropes and language. While not impossible, it does strain the boundaries of possibility.

Another piece of evidence is that Trump used his infamous sharpie to cross out “Corona” in his speech and replace it with “Chinese”, showing his use was intended, rather than a slip.  His defenders could engage in verbal gymnastics to explain this. One strategy was to argue Trump used the phrase “Chinese virus” as “Spanish flu” was used. While this approach has some appeal, using the phrase “Spanish flu” is also problematic. Labeling a disease with a specific country or ethnicity tends to lead to stigma and racism. As such, using the “Spanish Flu” defense is like defending the use of “wetback” by saying that people also used “wop.”

A second strategy is to argue that Trump was just referring to where it came from and, for bonus points, one can point out that it was originally called the “Wu Han virus.” One can say that it cannot have been racist or xenophobic for Trump to use “Chinese virus” because the Chinese used “Wu Han virus.” The easy and obvious reply is that the use of the term “Wu Han virus” was also seen as problematic, for the same reasons that “Spanish flu” and “Chinese virus” are problematic. To use an analogy, this would be like a Chinese leader talking about “Caucasian flu” and saying that was just fine because, for example, Americans first started using a term like “Connecticut flu” when the disease first appeared in Connecticut. Since Trump decided to refer to it as the “Chinese flu” and there are no good reasons to use that term, the best explanation is the obvious one: Trump used a xenophobic and racist dog whistle, cashing in on the well-worn trope of the diseased foreigner and the foreign disease. For those who would try to present this in a positive light, one must ask why do this? And why defend him against the umpteenth reasonable charge of racism and xenophobia?

As noted above, there was already racism and xenophobia against Asians (and Asian Americans) and Trump’s insistence on calling it the “Chinese virus” was likely to have contributed to the uptick in such incidents. Using this sort of label also put the United States at odds with other counties. And other countries blaming us had the same effect. Having Americans turn against other Americans is harmful, especially during a crisis in which community unity is an important part of our survival toolkit. It is also harmful to create conflict between nations when cooperation will improve our response to pandemics. A pandemic is a war between humans and a disease. Creating conflict between humans might serve the selfish goals of some leaders, but it harms humanity. As such, a key lesson from the COVID-19 pandemic is that using racism and xenophobia will only make things worse. As it always does.

In the face of a crisis politicians often have an incentive to conceal, lie and spread disinformation. There seems to be a natural impulse to do these things to avoid blame or perhaps from wishful thinking. A politician might have good reasons to conceal and deceive, such as to not seem weak to other nations or to avoid panicking the population. But concealing facts is likely to make things worse, while disinformation will make it even worse than that.

A lesson that should have been learned from the 1918 influenza pandemic is that honesty and accurate information are critical to fighting a pandemic. The threat of the flu was initially downplayed, allowing it to spread. Officials also failed to inform the public of the true danger. One example is the infamous Philadelphia parade which allowed the flu to spread like wildfire.  This resulted in the deaths of over 1,000 people and over 200,000 were infected. While this disaster should have provided a  lesson, the denial, downplaying and deceit continued. The inaction extended to the top, with President Woodrow Wilson (a Democrat) remaining silent about the flu. While there is no way to calculate  how many people would have not died if accurate information had been provided, it is reasonable to infer that many lives could have been saved.  Given this historical lesson, we should have been ready to face COVID-19 with honest, accurate information. But this was not the case. As an American, I will focus on my government, though examining other nations would also be useful.

When COVID-19 was first identified in January, former Trump officials  (Bossert and Gottlieb) started sounding a warning about the virus, drawing the obvious and tragic lessons from the 1918 pandemic. The initial response from Fox News was to cast the virus as a hoax intended to harm Trump.  According to Snopes, Trump did not directly claim the virus was a hoax but instead accused the Democrats of creating a new hoax—the target of the alleged hoax being his inept and dangerous handling of the virus.   This evolved into downplaying the severity of the threat, with Trump making dangerously false claims about the spread of the virus and other critical matters. While the White House and Fox news eventually seemed to take the threat seriously, dangerous disinformation was still being spread. One example of moral irresponsibility was the claim that test kits were readily available so that the federal government would be able to provide them to the states. This was not true and the lie costs states time they could have used to create and distribute their own test kits. It was as if your home was on fire and the fire department said that they were just about there with their great new firetrucks. But they were lying, they were not on their way and only had some garden hoses.

Because of the downplaying and deceit, there were deaths that could have been prevented by the truth. If Trump and Fox News had told the truth from day one, people would still have gotten sick, but we would have been better prepared and could have mitigated the harm. Instead, Trump and Fox News (and others) aided and abetted the viral enemy with disinformation and some deaths are partially their fault. 

The lessons from COVID-19 are a repeat of those of the 1918 pandemic: those in power need to provide honest and accurate information in response to public health threats. Such honesty can cost a politician, especially if they are ill equipped to handle the crisis. But the cost of silence and disinformation is always higher when it is paid by the public. But a leader’s concern should be the good of the people, not their own private good.

It could be objected that there have been cases in which silence and disinformation were beneficia. That is, the leaders’ concealment or lying caused a better outcome than the truth. While this might have some merit in some cases, the 1918 and 2019 pandemics shows this is a poor response to pandemics.  To claim there might be unknown cases in which silence or deception were the best choices would be to use an appeal to ignorance fallacy. Claiming silence or deceit is good because there might be unknown cases in which they worked is terrible logic. While the above focuses on politicians and leaders, it is also worth considering the threat of disinformation from members of the public.

As would be expected, citizens also spread misinformation. In some cases, this is the result of ignorance. People might act from benevolent motives, but they are doing harm by spreading untrue claims. For example, a person might believe that drinking bleach can cure COVID-19 and they share because they care. While benevolent motives cannot be faulted, people have an obligation to critically assess claims before they share them A quick test of a claim is to check it against one’s own observations, against one’s background information and against credible claims. Using the bleach example, bleach bottles have prominent warnings about the dangers of bleach (observation) and most people should have in their background information that bleach is a poison.  If a claim matches up with all three, then it is reasonable to accept it as likely be true. If it does not, then it is often reasonable to doubt the claim or at least suspend judgment. People also need to critically assess the sources of claims. If no source is provided, then one must go with the above methods of testing a claim. If a source is provided, the source must be confirmed and assessed. The credibility of source depends primarily on the knowledge of the source (how likely they are to be right) and their lack of bias (a biased source is less credible, since they have a reason to lie). In general, knowledgeable and unbiased sources are good sources; biased or ignorant sources are not. When in doubt it is wisest to suspend judgment.

There are also those who knowingly spread misinformation. This might be to make money, such as Televangelist Jim Bakker’s efforts to sell a fake corona virus cure or for political advantages, such as Russia’s efforts to worsen the pandemic by spreading disinformation in the West. There are also trolls who spread disinformation because it is amusing or because they want to hurt people. There is  no reasonable way to argue that it is morally acceptable for people to lie in health crisis to make money or because a troll likes engaging in harmful trolling. But perhaps a case can be made justifying nations weaponizing misinformation. After all, if using war or otherwise hurting and killing people are morally acceptable, then hurting people through misinformation would also seem acceptable. That is, if we accept killing people with bullets and bombs, then it is hard to balk at killing with lies.

One possible response is to argue that a pandemic is a war with two sides: humans and the pathogen. As such, when a country uses disinformation in a pandemic, they are aiding the enemy of all humanity and are committing treason in a time of war. A less dramatic and more pragmatic response is to point out that misinformation, like a virus, tends to spread, so a country that weaponizes misinformation runs the risk of it infecting their own population. Social media is, of course, the vessel of choice for distributing most disinformation and misinformation.

While there can be sensible debate about what sort of political speech social media should restrict, if any, there seems to be no good arguments that social media companies should allow and enable the spread of misinformation and disinformation about a pandemic. Returning to the virus analogy, this would be like Uber having a policy of allowing drivers to knowingly drive  people infected with dangerous diseases around to interact with healthy people just because they can make some money. There is also the war analogy. If social media does not fight misinformation and disinformation in a pandemic, they are aiding and abetting the enemy in a time of war.

In closing, the lessons here are clear: leaders need to immediately provide accurate information about pandemics, citizens need to be critical in their acceptance of information, and intentional spreading of disinformation should be regarded as moral crime against humanity in a time of war.

When everyone is in danger from a disease, it seems irrational for a political party to politicize the threat. But this happened during COVID-19.  One reason is that while Americans seem extremely polarized; this is  more appearance than reality. While Americans do disagree strongly on some issues, there is considerable consensus about many issues. Because of this, political parties need to manufacture a conflict in which they can score points. Since a threat generates strong emotions, it can be ideal for politization as a party can tap into the emotions and manipulate them to its advantage. Taking a threat seriously can also be contrary to the interests of some and they will try to prevent this by politicizing the threat. If they succeed, they can recruit voters and get them to support policies that endanger these voters. Thus, a political party can have two excellent reasons to politicize a universal threat: to score political points and serve the interests of those who benefit from allowing the threat to remain unaddressed.

Politicization can be effective at engaging emotions and disengaging reasoning. There are many fallacies (such as group think) and cognitive biases (such as in group bias) that feed and are fed by ideology. If you are liberal, then you probably just thought of the Republican politicization of climate change. If you are a conservative, you might have been thinking about the sins of the Democrats. If so, then you can see how conflict can easily be created along party lines.

The COVID-19 virus presents a threat to everyone, but it was politicized. Initially the Trump administration downplayed the virus and accused the Democrats of using it to attack Trump and the idea that is a hoax aimed at hurting Trump persists. There were short-term advantages to politicizing the virus, such as keeping the markets calm through ignorance, to allow business to continue as usual and to hope that the virus would not arrive until after the 2020 election. Political points were also scored against the Democrats by accusing them of making up a virus threat to hurt Trump.

From the Republican perspective, the Democrats were the villains, doing terrible things to harm Trump and impede his efforts. On their view, it was the Democrats who were manufacturing the conflict; first by creating a virus hoax and then by interfering with Trump’s efforts to address the virus.  How one sees this matter will, obviously, tend to shake out along ideological lines, thus politicizing the issue of politicization.

While, as noted above, political points can be scored by politicizing an objective threat, this does have negative consequences. The most obvious is that time and resources are spent fighting manufactured political battles rather than uniting against a threat to everyone. Another consequence is that manufacturing a conflict requires that misinformation, thus misleading people and this can have enduring consequences. In the case of the virus, while Fox News and the White House did shift their position to match reality, the groundwork they laid still serves as a foundation for the enduring view that the virus is either a hoax or not very serious.

Some Republicans will want to blame the Democrats; a common narrative is that their impeachment efforts are partially to blame for the virus crisis. As would be expected, one’s ideological lens determines how one sees this matter: Trump and Fox News as the villains who politicized the virus or the Democrats as the villains who distracted Trump from the virus.

There are three solutions to the needless harm caused by this sort of politicization. The first is that politicians need to exercise judgment and restraint before engaging in politization of a crisis. The problem is that it is seen as a useful political tool. As such, getting politicians to use good judgment and exercise restraint is challenging. The second solution is that voters can support candidates who are more likely to exercise judgment and restraint. Third, voters also decide how they respond. If they resisted efforts to politicize a crisis that should be non-partisan, then the efforts of politicians would be far less likely to succeed.

One concern is the charge of politization can be used, ironically, to politicize an issue and silence legitimate criticism. For example, the facts show that Trump’s initial handling of the crisis was terrible and that he made untrue claims about the virus and the situation. As such, legitimate criticisms of these failures could be non-political. But if critics are Democrats or liberals, they could be accused of politicizing. To address this problem, critics should focus on the facts and steer clear of what might appear overtly political. This will be challenging, since the other party is unlikely to accept legitimate and fair criticism and will claim it is unfair politicization. As such, the manufactured polarization in the United States that has served the parties has done massive damage to America. As should be expected. Unless we address this, new crises will  repeat the harmful politicalization of the  COVID-19 crisis.

In the United States, health care is often seen as a private good. The benefit of a private good belongs primarily (or even exclusively) to the individual. But a private good could have some broader benefit as well. A private good is usually seen as being the responsibility of the beneficiary. Put roughly, you should pay for your private good, not the rest of us. There are many things that are clearly private goods.

For example, my running shoes are a private good because they benefit me, and I should be the one to buy them.  In terms of broader benefits, my health means that I do not miss work, and this benefits my employer and students. But this is not enough to make them a public good.  .

Obviously. a public good is supposed to benefit the public and is often seen as being the responsibility of society. Put roughly, it is a good for us and we should pay for it collectively. A public good need not benefit everyone directly. For example, public transport does not directly benefit someone who never uses it and only gets around by walking or biking.  There is considerable debate over what goods (if any) should be public. Public versus private health care is a matter of debate in the United States.

Apart from the United States, most wealthy countries have chosen public health care. The United States offers some public health care in the form of Medicare and Medicaid but people need to qualify for both and the Trump administration and Musk are doing what they can to cut into these programs.

Most working people rely on private health care. One reason is the rhetorical narrative that health care is a private goo or at least better as a private good. In terms of being a private good, the idea is that each of us is responsible for our own health care in that we must earn the money to pay for insurance and treatment. With the exceptions of Medicare and Medicaid, we are on our own. The idea is that my health is good for me, but not for you, hence I should bear the cost.

There are also arguments that private health care is better than public health care. This can be countered by the fact that people go bankrupt due to medical expenses, people cannot afford and hence do not get basic care, and people  turn to GoFundMe to pay their medical bills. It is true that we have the best health care money can buy, if you have the money to buy it. I will set aside this debate to focus on the main issue: whether health care is best seen as public or private good. One way to approach this matter is to consider paradigm cases of public goods.

Consider, if you will, an alternative America in which defense, police, fire and the legal system are private goods analogous to how health care is a private good in the real America. In this alternative America, citizens need to purchase military, police and legal insurance or face high costs for purchasing military, police, fire and legal services. In the case of military and police coverage, a citizen would be provided with various degrees of military protection for their person and property. Without such coverage, a citizen would need to pay high costs to secure such services as defense against foreign enemies and police investigations into crimes committed against them. Those who could not pay might be able to qualify for some basic services through government programs such as Militaryaid and Policecare. Those unable to qualify for these programs and unable to afford the services would be on their own. They would need to rely on self-defense, a garden hose and vigilante justice to address threats and crimes against them. This would be fair and just—after all, having the military protect me does not benefit you, nor does having the police investigate theft of my truck benefit you. Only having the military protect you benefits you. Only having the police investigate the theft of your truck benefits you. So, by the logic of health care as a private good, police and military services are also private goods. The same would also apply to aspects of the legal system. Being able to defend my property or other rights in a legal system does not benefit you, it just benefits me.

There would be, of course, certain police, military and legal activities that would occur because they would be good for these institutions and the state. The police would certainly enforce laws that generated revenue for them and the state; but if the law served only your private good, then you would need to pay for its enforcement. Such institutions would be lean and efficient, operating in accord with strict market forces as God intended. Unless, of course, they grew bloated and inefficient.

In this world, the results would be like health care in the real world. People would be locked into jobs to keep their police, military, fire and legal benefits. People in need would turn to GoFundMe to pay to have their spouses’ murder   investigation or keeping Canadians off their land. Many people would be victimized, injured or killed because they lacked basic coverage. But defenders of the system would praise it for all it alleged virtues and mock other countries for their public police, military, fire and legal services.

Things like police, military, legal and fire services are seen as public goods because they meet a state’s minimal obligation of protecting its citizens. Such goods require large expenditures, thus requiring collective funding and this can be seen as justifying providing a collective good. The same can be applied to health care; just as the state should protect its citizens from ISIS, fire and crime, it should also protect its citizens from COVID-19 and cancer. After all, you are dead whether you are killed by an ISIS bomb, a criminal’s bullet or COVID-19.

Police, military and other such services are also seen as public goods because they do (mostly) benefit everyone—even though the specific applications benefit specific people. The same also applies to much of health care. For example, infectious illnesses spread and containing them is a public good. As another pragmatic example, sick and injured people contribute less to the economy, so treating them benefits the public by getting them back into serving their core functions in capitalism: working and spending. As such, health care should be seen as analogous to the public goods of the military, police, fire, and legal system. There are, of course, obvious exceptions in which medical procedures are entirely private goods (like face lifts) but these exceptions do not disprove the general principle.

When the COVID-19 virus invaded the United States, it found an ill-prepared and complacent foe. As such, the impact proved devastating. One clear lesson is that the aggressively for-profit health care system is a weak point in our national defense against disease. I will make my case with the obvious analogy between health care and military defense.

Imagine, if you will, that the United States military operated like our health care system. Our current health care system is analogous to relying on mercenaries, albeit with a professional code of ethics and some loyalty to the nation. During normal times, the health care system is almost entirely mercenary: it fights battles to make a profit. This is not to disparage medical professionals, but the profit model chosen by those who control health care. Because the goal is profit, the health care system is operated to minimize costs and maximize income. This means operating like a mercenary force: employing minimal personnel to do the job, maintaining only necessary resources for normal operations, focusing on the highest paying customers, and only taking on profitable contracts. This is a rational way to operate a mercenary unit. But is it a good way for a national military to run? That is, would it make sense for the United States to switch from a public military to a mercenary military?

Laying aside the usual problems of loyalty and dependability, relying on a mercenary (for-profit) military model would be a problem for the United States. One obvious problem is the United States needs a large force that ready to engage in prolonged conflicts that we do not always get to pick. After all, national security need not match up with what would be the most profitable military operations and requires keeping resources available, such as the reserves, that no purely for-profit military would sensibly maintain. If the United States relied on a mercenary military for its defense, it would face many challenges in times of crisis: rapidly ramping up to meet the challenge, making the operations profitable enough to motivate mercenary forces (such as paying them enough to protect everybody). These are, in fact, all the reasons why a country should have a public, national military rather than relying on mercenaries. After all, the United States needs a military that is ready to face whatever threat arises and not a force limited by the need to make a profit. It is thus no surprise that our mercenary healthcare system runs into analogous problems.

Being focused on profits, the health care system operates with minimum resources and personnel. Maintaining a reserve of medical professionals and the resources needed for a crisis would cut deeply into profits. The government, it should be noted, does keep some medical resources in reserve, but this is obviously the public sector in operation. Because of this razor thin operation that maximizes profits, the health care system is like a mercenary unit: ill-prepared when the battle turns into a full-scale war requiring large reserves and resources. The health care system normally deals with the problem of resources by allocating them based on profit; like a smart mercenary commander who accepts the lucrative contract to fight easier opponents. In the case of health care, the wealthy get the best health care money can buy, while the poor get whatever is left over. But in the case of a national crisis, the response must be large scale: it is an invasion and not just the usual battles. People face the same problem, be it in a battle fought by mercenaries or health care provided by mercenaries: they need to be able to pay in order to get protection.

One principled reason we have a national public military rather than using mercenary forces is that we accept that the military should protect all citizens and not just those who can afford to hire their own mercenary forces. The same principle should apply to health care: having a mercenary medical system means that a citizen’s survival depends on what they can pay, and this is not acceptable. If we believe that the state should protect all citizens equally from ISIS and North Korea, then we should accept that the state should protect all citizens equally from COVID-19 and H1N1.

It could be sensibly argued that the military model fits in the case of pandemics and while health care should be modified to address the threat of pandemics, the for-profit model should remain for everyday medical matters. So, for example, everyone should have access to testing and treatment for COVID-19, but we should still be on our own when it comes to the flu, hepatitis or automobile accidents.

One reply is to argue that the state has obligations in the everyday medical care of the citizens. To use another analogy, if handling pandemics is like fighting a war, lesser threats are analogous to small-scale conflicts or police operations. We do not, for example, expect Americans to pay to get police services to address crimes against them, just because the crime is against them and not a pandemic of crime.

This is not to say that the state must pay for everything. No doubt someone is thinking about the state  paying for breast implants or face lifts. But expecting the state to pay for these would be like expecting the state to pay the bill because a citizen wanted to see a military parade on their street. As such, only the medically necessary should be covered. Just as we limit the obligations of the national military and local police, the obligations of health care can also be limited. This can lead to debates about what is necessary, but these disputes can be addressed in good faith.

It could be objected that people bring on their own health problems by bad choices and this should not be the responsibility of the state. But the same argument would apply to the police and military. For example, if the police thought that you did not take enough precautions to protect your car, they could refuse to do anything about it being stolen. Or, as another example, if you get attacked and injured, they could refuse to help you because you failed to take enough karate.

If we continue to rely on mercenary health care as part of our national defense, we can expect things to play out in a manner analogous to relying on mercenary forces for our national defense: no matter how brave or dedicated the individual soldiers are, a mercenary system is simply not up to facing the challenge.

One the face of it, it is reasonable to think a mass shooter must have “something wrong” with them. Well-adjusted, moral people do not engage in mass murder. But are mass shooters mentally ill? The nature of mental illness is a medical matter, not a matter for common sense pop psychology or philosophers to resolve. But critical thinking can be applied to the claim that mass shootings are caused by mental illness.

Using the strict medical definition, mentally ill people do not make up the majority of mass shooters and about 3% of violent criminals are mentally ill. Research consistently shows that the mentally ill are more likely to be victims of violence rather than perpetrators. Violence on the part of the mentally ill tends to be self-directed rather than directed at others.

Self-injury is a matter of concern, but mass shootings and gun violence are not primarily a mental health issue. While the mentally ill commit some gun violence, focusing on mental illness as the primary means to reduce gun violence would be an error, except to address cases of self-harm.

It could be objected that the definition of mental illness used above is too narrow and that engaging in a mass shooting is evidence of mental illness because a sane person would not do such a thing. While this has some appeal, expanding the scope of mental illness to automatically include those who engage in mass shootings would be problematic.

One obvious concern is that soldiers and police could thus be classified as mentally ill simply by being involved in shootings on par with a mass shooting. It could be countered that soldiers and the police (usually) use violence legally and rationally while mass shooters and people engaging in other gun violence do not. While it is true that mass shootings and gun violence are illegal, mass shooters do often act from grievances and ideology, just as soldiers and police are sent to kill over grievances and in accord with an ideology. As such, killing people for these reasons does not make someone mentally ill, unless we want to classify combat veterans and some police officers as automatically mentally ill. As far as the legal aspect is concerned, breaking the law hardly seems to show someone is mentally ill, otherwise all criminals would be insane and thus would always succeed in the insanity defense.

A second concern is that assuming mass shooters are mentally ill would eliminate the role of evil. If people do mass shooting things because of mental illness, then they are not evil in a morally meaningful sense. While this could be true, such an approach to evil would need to be applied consistently and not just to mass shootings. So, for example, when terrorists crash planes into buildings or blow up a wedding, they are suffering from mental illness and are not evil. One could attempt to work out accounts of ethics and mental illness that put the blame for gun violence on mental illness while putting the blame for terrorism on evil, but this would be challenging. After all, if a white supremacist kills people because he is mentally ill, then the same would apply to a member of ISIS. Interesting enough, while Republicans and the NRA rush to blame mass shootings on mental illness, they do not do the same for terrorism or other crime and it is interesting to compare the rhetoric used by the same pundit or politicians to describe these situations. This is not to say that a case cannot be made for eliminating the concept of evil in favor of the concept of mental illness, but this must be done in a principled manner and applied consistently.

Considering the above discussion, the mental illness explanation for mass shootings (and gun violence) is not adequate. While seriously addressing mental illness would be laudable, it would not eliminate mass shootings and would have an insignificant impact on most violence (other than self-inflicted violence). This is not to say that mental illness should not be addressed, it absolutely should. But claiming mental illness explains gun violence is an error and a distraction from addressing the causes of gun violence.

According to the FDA, it “is responsible for protecting the public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological products, and medical devices; and by ensuring the safety of our nation’s food supply, cosmetics, and products that emit radiation.” Given this mission, the FDA should put the interest of public health ahead of other concerns, such as the profits of a pharmaceutical company. While many at the FDA are dedicated to this mission, federal agencies are routinely captured by industry. So, it is not surprising that the FDA has benefited companies at the expense of public health. Charles Seife wrote an article that appeared in the February 2018 issue of Scientific American. While there are legal issues here, my concern is with ethics

On the face of it, the moral problem is easy to solve. As the FDA is tasked with protecting public health, its moral duty is to do that. Putting public health at risk to benefit a company or individual would be wrong. Part of the problem, as noted by Seife, is that the FDA is secretive, which makes it difficult for the public to know about the FDA and the products it approves. Another part of the problem, also noted by Seife, is that the FDA seems willing to allow research misconduct to remain unreported. Under the current administration, it seems likely that things will only get worse.

While it is tempting to see evidence of misdeed when drugs are recalled or given new warnings, it must be noted that this should be expected even when products are properly evaluated. This is because of how inductive reasoning used in product trials works. While inductive logic is essential, it has a fundamental problem that is called, shockingly enough, the problem of induction. Since an inductive argument’s conclusion always “leaps” beyond its premises, the conclusion of such an argument can always be false, even when all the premises are true. Since the controlled experiments of the trials are inductive, they can be properly conducted  and still yield a false conclusion. These trials are then generalized to the entire population, which is another inductive argument and another chance for things to go wrong.

For example, even a large sample will not contain every genetic or physiological variation relevant to drug interactions. As such, a drug that was safe in the trials might have unexpected results out in the wild. So, one should not rush to judgment if an approved drug needs a warning label revision or has unexpected effects on some people. That said, the concern about how the FDA operates remains, as Seife’s research indicates.  As such, the FDA seems to have acted wrongly by putting corporate interests ahead of public health. It remains to be seen what the future will bring, but even under traditional administrations, the FDA has engaged in bad behavior. If even this modest oversight is stripped away, things will become much worse.

An obvious solution is to make the FDA’s process and data available to the public. Under this solution, the public would have access to everything that occurs within the FDA as well as all the information provided to the FDA by the companies whose products are being evaluated. While this would solve the problems noted above, there are reasonable concerns about such complete transparency.

Allowing full public access to the FDA’s information would also allow the same access to competing pharmaceutical companies (and others with a financial interest in the data). Such transparency would allow access to a company’s trade secrets, commercial and financial information.  This could cause “substantial competitive injury” and would be like playing poker while being forced to let everyone see your cards. Because of the potential harm, such full transparency would seem to be wrong.

It could be countered that all companies would be on equal footing, and no one would have an advantage. Going back to the poker analogy, if everyone must show their cards, no one has an advantage. The obvious problem is that foreign companies that do not undergo FDA approval would have access to the data and this could give them an edge against companies that sought FDA approval.

Another counter is to argue on utilitarian grounds: even if transparency harmed companies, the advantage to public health would outweigh this. But this could be countered by arguing the reverse. As these concerns are reasonable, complete transparency is morally problematic under the current economic system. As such, what would seem to be needed is an approach that protects the public while also protecting the legitimate interests of companies.

As Seife noted in his article, the information the FDA has kept from the public includes data about harmful side-effects and concerns about the efficacy of products. This information has been redacted or withheld based on the harm that would be done to the company if the truth were known. While it is true that releasing such information could harm a company’s profit, this is not a morally acceptable reason. After all, the mission of the FDA is to protect public health; protecting private profit at the expense of public health is a violation of this mission.

While a company or individual does have a right to keep certain information private, this right does not extend to concealing danger to others. To use an analogy, while I do have the right to keep my medical records private, I do not have the right to keep it a secret if I were infected with Ebola. To use another analogy, while a company would have a right to keep its manufacturing process for snacks secret, it has no right to keep secret the fact that the main ingredient is rats. The public does not have a right to know their trade secrets; but they do have a right to know if the snacks contain rats. Likewise, while the public does not have a right to know the legitimate trade secrets of a drug company, they do have the right to know the side-effects and efficacy of the drugs they take. As such, the FDA can fulfil its proper mission of protecting public health while also protecting legitimate trade secrets. Companies that want to profit on concealing data from the public with FDA collusion might be dismayed by this, but they have no moral right to expect this—especially when they can still make massive profits by making safe and efficacious drugs.

Considering the actions of the current administration, it is terrifying to consider how much worse things could become. Information about side-effects and ineffective drugs have been concealed in the past, but Trump and Musk are dedicated to dismantling the federal government, including the FDA. In the best of times, it did not protect us very well and it is reasonable to think it will become much worse. While it is always wise to be cautious about drugs and procedures, it would be prudent to be extremely cautious about forthcoming FDA approvals.

While the United States has the best health care money can buy, many Americans cannot afford it. Many Americans are underinsured or not insured and even the insured might face denial of coverage. Americans, as their response to the execution of a health care CEO, are aware of this. Most politicians, with the exception of people like Bernie Sanders, have put their faith in the fact that people forget quickly and have done nothing to address this problem.

A lack of insurance puts the health of the uninsured at risk and health care institutions suffer financially. Medical bankruptcy also occurs at an alarming rate.  Because of these problems, there have been proposals to extend Medicare to all Americans.

On the positive side, this would provide everyone with health insurance. This would benefit those without insurance and would also help the finances of healthcare institutions. As the system already exists, it would mostly be a matter of scale. This would come with serious challenges, but they are obviously not insurmountable. While there are clear advantages to expanding Medicare, a rational assessment requires looking beyond the positive aspects and, as much as possible, without the filters of ideology.

An obvious concern is the cost of such an expansion. Those who already pay for insurance would not suffer any financial impact from the switch, unless the cost of Medicare was significantly higher than what they are paying now.  As the cost could have negative impacts on the economy and individuals, it needs to be assessed rationally.

A second concern is the impact on the health insurance industry. While some might be tempted to think that only the CEOs would suffer, the insurance industry is made up of a range of people who depend on their jobs to survive. Switching to Medicare for all would eliminate the private health insurance industry and put people out of work directly and indirectly. Somewhat ironically, those on the right who oppose Medicare expansion usually see firing workers as a positive thing while those on the left express concern for workers. One possibility is that former insurance workers could be retrained and hired to work for Medicare, assuming that it is not swept away in the current zeal to destroy government agencies and programs that protect and benefit non-billionaires.

 It is also worth considering other economic aspects. While it should not be assumed that this cost will be too high relative to the benefits, this cost needs to be considered. Again, while it is appealing to think that eliminating private insurance would only harm evil CEOs, the effects on others should be considered. But given the tremendous harm Americans suffer from the current system; its replacement would certainly do more good than harm.

A third concern is fraud. While fraud does occur with private health insurance, Medicare is sometimes a cash cow for fraudsters. In 2014 about 10% of Medicare’s total budget was lost to fraud. Expanding Medicare to everyone would turn the cash cow into a cash herd. Fraud could and should be addressed even if Medicare is not expanded, but the cost of fraud must be included in the calculations used to assess the merits of expanding Medicare. While the right advances the narrative that it is poor people who defraud the government, the evidence is that it is the wealthy. This does make intuitive sense: if the poor were as good at committing fraud as the right claims, they would no longer be poor. But even with the inevitable fraud, an expansion of Medicare would be superior to the existing system, which siphons money from Americans into the accounts of CEOs.

A fourth concern is usually advanced by conservatives, namely that the elimination of the for-profit motivation will ruin the quality of health care with socialism. One reply is to note that health care will remain for-profit: Medicare for all does not nationalize health care institutions, just the insurance industry. And the motivation provided by the for-profit approach is to profit more, and that typically involves worse rather than better medical care.

That said, it could be argued that with one entity paying all the bills costs will increase and quality will decrease—but what is needed is evidence for these claims. If they are true, then this would be a problem that could be addressed. The rest of the world

In July of 2002 the New England Journal of Medicine published a study on arthroscopic surgery.

The experimental group members underwent surgery while the control group received placebo surgeries.  Somewhat surprisingly, those receiving the placebo reported feeling better and performed better at walking and stair climbing than those in the experimental group. After reading this study, I wrote “Lies…the Best Medicine?” and it appeared in my What Don’t You Know? While working through my massive backlog of magazines, I came across an update on placebo surgeries in Scientific America in which Claudia Wallis argued in favor of fake operations. Reminded of my ancient essay, I am revisiting thoughts on the ethics of placebo surgeries.

As in my old essay, I think that there is a good argument against placebo surgery. Treating a patient with a placebo requires deception. If the effect requires the patient to believe they have received surgery, then the patient must be convinced of an untruth. If the medical personnel are honest and tell the patient the the surgery was fake, then they would, presumably, not benefit from it. If it is wrong to lie, then this deceit would be wrong. What would make it even worse is that medical personnel should be honest with patients.  Thus, even if placebo surgery is effective or even more effective than real surgery, then it should not be used.

One counter to this argument is that even when patients know they are receiving a placebo, it can still be effective. Medical personnel could be honest with patients about a placebo surgery and, perhaps, still maintain the effectiveness of the non-treatment. This would allow the use of placebo surgery while avoiding the moral problem. However, this does not solve the problem for cases in which patients must not know whether they are receiving surgery or the placebo. Placebo surgery is often used to test the effectiveness of surgeries in a rigorous manner. If the surgery is no better (or even worse) than a placebo, then there would be no medical reason to use the surgery over a placebo or no surgery at all.

It can be argued that deception in such situations is acceptable. One approach is to use examples of acceptable, beneficial deception. Obvious examples include the benign deceits about Santa Claus, the Easter Bunny and the Tooth Fairy. As another illustration, there are lies people tell to avoid causing others suffering. If this sort of benign deceit is acceptable, then so is the use of deceit to produce the placebo effect or to conduct a study for the greater good.

A second approach is to focus on the purpose of the medical profession. While philosophers and scientists are supposed to seek the truth, the end of medicine is to relieve pain and prevent or cure illnesses. If deception, in the form of a placebo, can achieve the end of medicine, then it is one more tool, like a scalpel or drug. In fact, it could be argued that effective placebos are even better than drugs or surgery. Surgery always involves some risk, and most drugs have side effects. Placebos would, presumably, involve little or no risk. That said, it is worth considering that there could also be mental side-effects with placebos.

Since placebo treatment is usually not free, it could be objected that it is still wrong: patients are charged, and nothing has been done for them. If medical personnel were using placebos to cover up illnesses and injuries while pocketing profits from fake treatment, then that would be unethical. However, if the treatment is honest and works then it would be as legitimate as any other form of treatment. So, if a patient needs to see a doctor to get the placebo effect working properly and it works as well or better than the “real” treatment, then it is as reasonable to bill for the placebo treatment as it is a real treatment—although the price should be adjusted accordingly. If the placebo effect could be created without involving medical personnel, then charging patients for it would be unethical.

In the case of studies in which the subjects are not paying, then there would be no special moral concern for the use of the placebo. Its use would, in fact, be required for a proper experiment. This does raise the usual moral concerns about conducting experiments, but that is a subject worthy of consideration on its own.