August 26, 2009


The concept of hyphen-ethics is most relevant in the field of bioethics where health care issues are inextricably linked with the market and the perceived needs of the health industry (medical professionals, pharmaceutical companies, fund-raising organizations such as cancer research fund-raisers) to enjoy economic health. It is not just about caring for the human need for well-being or even a freedom from suffering although this is the subject of current debates on universal health care. Who will decide what is a human need and what is a want in terms of defining basic, adequate, essential and/or discretional health care access. When and where do health resources end? What are the ends of medicine? What is the nature of medicine? What are the limits to imposed regulations and health care?

The calm witness in the debate on universal health care, a man married to a long-term cancer survivor, is concerned that proposed federal regulations, would deprive him of the current level of health care services his family needs. In a closer reading of his family’s story, his wife’s free access to a $60,000 treatment was through an act of philanthropy on the part of the treatment providers. Would this be affected by providing access to others who are lacking insurance or who have inadequate insurance? Her other medical bills were paid through his work plan. But what if he, like so many others today, suddenly no longer had an employer who provided a health plan? Perhaps what he is really expressing is gratitude for what he was able to receive and hope that others will be as fortunate when faced with a family health crisis.

In 1981 philosopher Amy Gutmann published an article entitled, “For and Against Equal Access to Health Care” in the Milbank Memorial Fund Quarterly. When the article was reprinted in 1999, the editors described how, “The Gutmann piece was written long before the failure of the Clinton plan but it still remains a classic argument for a national or universal health care system. A principal feature of her argument is that a one-class health care system, one for the rich, the middle classes and poor alike, promotes a health care system that caters to the needs of the better off as well as the poor, and this will strengthen the overall system level of benefits. Gutmann for practical political reasons acknowledges that a one-class system could not go so far as to forbid the rich from purchasing more health care outside the system, spending out of-pocket (Beauchamp; Steinbock 1999:253).”

“I suspect that no philosophical argument can provide us with a cogent principle by which we can draw a line within the enormous group of goods that can improve health or extend life prospects of individuals . . . The remaining question of establishing a precise level of priorities among health care and other goods is appropriately left to democratic decision-making (Gutmann 1981: 542-60)

Because of his close advisory position with President Obama on health care issues, Ezekiel J. Emanuel’s opinions are being scrutinized. In his article (1996-11/12) entitled “Where Civic Republicanism and Deliberative Democracy Meet,” seems to misinterpret Gutmann’s arguments as extremely dangerous moral skepticism. Emanuel assumed that she concluded, that there can be no principled mechanism to define basic health care services and, therefore, that the efforts to ensure universal access will always founder on the fear that guaranteeing any health care to all citizens means guaranteeing all available services. It suggests we should just give up on a just allocation of health care resources because we can never succeed (Emanuel 1996:13).” Emanuel misread her carefully worded debate in which she succinctly summarizes various perspectives on access to health care in the pre-Clinton health care debate period. In one scenario she traces the unintended consequences of imposed universal access in an imperfect world and goes on to suggest a pragmatic solution. In fact Gutmann concludes, “I began by arguing that a principle of equal access to health care was at best an ideal toward which our society might strive. I shall end by qualifying that statement. A sufficiently high level of public provision of health care for all citizens and a sufficiently elastic supply of health care would significantly reduce the threat to universal provision of quality health care of a private market in extra health care goods, just as a very high level of police protection and education reduces the inequalities of opportunity resulting from purchase of private bodyguards or of private school education by the rich. In the best of all imaginable worlds of egalitarian justice, the equal access principle would be sufficiently supported by other egalitarian social and economic institutions that a market in health care would complement rather than undercut the goals of equal respect and opportunity. But philosophers ought to resist basing their political recommendations solely upon a model of the best of all imaginable worlds (Gutmann 1999 [1981:253]).”

Emanuel (1996:13)

suggests that, “Regardless, a refined view has emerged that begins to overlap between liberalism and communitarianism. This overlap inspires hope for making progress on the just allocation of health care resources. This refined view distinguishes issues within the political sphere into four types: (1) issues related to constitutional rights and liberties; (2) issues related to opportunities, including health care and education; (3) issues related to the distribution of wealth such as tax policies; and (4) other political matters that may not be matters of justice but are matters of common good, such as environmental policies and defense politicies. While there still may be disagreement about the need for a neutral justification for rights and liberties, there is consensus between communitarians and liberals that policies regarding opportunities, wealth, and matters of the common good can only be justified by appeal to a particular conception of the good. As Rawls has put it:

Public reason does not apply to all political questions but only to those involving what we may call “constitutional essentials.”3 (Emanuel 1996:13).”

TBC

1960s the dominant social issue of the 1960s and 1970s was that of justice and equality. Given that context, it was hardly surprising that the field of bioethics saw a great surge of writing and debate on issues of justice and health care.(Daniels, Emanuel and Jennings 1996).

1970s the dominant social issue of the 1960s and 1970s was that of justice and equality. Given that context, it was hardly surprising that the field of bioethics saw a great surge of writing and debate on issues of justice and health care.(Daniels, Emanuel and Jennings 1996).

1972 John Rawls’ 1972 study A Theory of Justice “was not only a powerful work in its own right but perfectly in step with the times. Given that context, it was hardly surprising that the field of bioethics saw a great surge of writing and debate on issues of justice and health care. That was, and still is, a central topic. Far less important for many years was any serious discussion of the ends of medicine. To be sure, there was and is a field known as the philosophy of medicine that has given considerable attention to the nature of medicine. But the discussion in that field – which was often technical and historical in any case, self-consciously academic and scholarly – proceeded independently of the interest in health care equality. And vice-versa. In retrospect, that seems an odd bifurcation. How is it possible to have a full examination of a field as dynamic and fast-changing as health care without – simultaneous – asking some basic questions about what health care is supposed to give us and do for us? Norman Daniels, in his fine work on justice and health care, has come as close as anyone to attempting to find the specific link between the ends of health care and fair access to it. By his use of the concept of species-typical functioning as the goal of medicine he has sought to (Daniels, Emanuel and Jennings 1996).

1981 Philosopher Amy Gutmann published an article entitled, “For and Against Equal Access to Health Care” in the  Milbank Memorial Fund Quarterly. “The Gutmann piece was written long before the failure of the Clinton plan but it still remains a classic argument for a national or universal health care system. A principal feature of her argument is that a one-class health care system, one for the rich, the middle classes and poor alike, promotes a health care system that caters to the needs of the better off as well as the poor, and this will strengthen the overall system level of benefits. Gutmann for practical political reasons acknowledges that a one-class system could not go so far as to forbid the rich from purchasing more health care outside the system, spending out of-pocket (Beauchamp; Steinbock 1999:253).”

“I suspect that no philosophical argument can provide us with a cogent principle by which we can draw a line within the enormous group of goods that can improve health or extend life prospects of individuals . . . The remaining question of establishing a precise level of priorities among health care and other goods is appropriately left to democratic decision-making (Gutmann 1981: 542-60)

1996 Norman Daniels, Ezekiel J. Emanuel and Bruce Jennings co-authored the Hastings Center Report entitled “Is Justice Enough? Ends and Means in Bioethics. “There call be little doubt that the dominant social issue of the 1960s and 1970s was that of justice and equality. It inspired the development of many fresh welfare policies and was a potent motivating force in the advent of Medicare and Medicaid, both thought (mistakenly as it turned out) to be the forerunners of universal health care. John Rawls’ 1972 study A Theory of Justice was not only a powerful work in its own right but perfectly in step with the times. Given that context, it was hardly surprising that the field of bioethics saw a great surge of writing and debate on issues of justice and health care. That was, and still is, a central topic. Far less important for many years was any serious discussion of the ends of medicine. To be sure, there was and is a field known as the philosophy of medicine that has given considerable attention to the nature of medicine. But the discussion in that field – which was often technical and historical in any case, self-consciously academic and scholarly – proceeded independently of the interest in health care equality. And vice-versa. In retrospect, that seems an odd bifurcation. How is it possible to have a full examination of a field as dynamic and fast-changing as health care without – simultaneous – asking some basic questions about what health care is supposed to give us and do for us? Norman Daniels, in his fine work on justice and health care, has come as close as anyone to attempting to find the specific link between the ends of health care and fair access to it. By his use of the concept of species-typical functioning as the goal of medicine he has sought to (Daniels, Emanuel and Jennings 1996).

1996-11/12 Ezekiel J. Emanuel’s article entitled “Where Civic Republicanism and Deliberative Democracy Meet,” cautioned that Gutmann and Daniels’ moral skepticism was extremely dangerous. [I]t suggests that there can be no principled mechanism to define basic health care services and, therefore, that the efforts to ensure universal access will always founder on the fear that guaranteeing any health care to all citizens means guaranteeing all available services. It suggests we should just give up on a just allocation of health care resources because we can never succeed (Emanuel 1996:13).”

1999 “Most books about ethics and health focus on issues arising from individual patients and their relationships with doctors and other health professionals. More and more, however, ethical issues are challenges that face entire communities, not just individual patients. This book is an edited collection of readings that addresses these public health challenges. Many of the issues considered, such as policy for alcohol and other drugs, newly emergent epidemics, and violence prevention, are public health concerns beyond the purview of traditional bioethics. Others, such as access to health care, managed care, reproductive technologies, and genetic testing, are covered in bioethics texts, but here they are approached from the distinct viewpoint of public health. The book makes explicit the community perspective of public health, as well as the field’s emphasis on prevention. It examines the conceptual issues raised by the public health perspective (i.e., what is meant by community, the common good, and individual autonomy) as well as the policies that can be developed when health problems are approached in population-based, preventive terms.” Amazon abstract of: Beauchamp, Dan E.; Steinbock, Bonnie. 1999. New Ethics for the Public’s Health. Oxford University Press. This book includes the

Limited preview – 1999 – 382 pages

2001 In his controversial article entitled “Terminating Life-Sustaining Treatment of the Demented,” Dan Callahan (Callahan 2001:93) claimed that euthanasia is necessary for patients suffering from terminal illness. Opponents claim that euthanasia is immoral and violates reason.

2009-07-17 Senator Edward Kennedy (1932-2009): “We will end the disgrace of America as the only major industrialized nation in the world that doesn’t guarantee health care for all of its people (Kennedy Newsweek).”

“Is there a relationship between defects in our medical ethics and the reason the United States has repeatedly failed to enact universal health coverage? I will begin to suggest an answer to this question by clarifying the locus of allocating decisions. The allocation of health care resources can occur on three levels. The social or, in the economist’s language, the macro level entails the proportion of the gross national product (GNP) allocated to health care. The patient, or micro, level entails determining which individual patients will receive specific medical services; that is, whether Mrs. White should receive this available liver for transplantation. Finally, there is an intermediate level called the service or medical level that entails determining what health care services will be guaranteed to each citizen. These socially guaranteed services have been called “basic” or “essential” medical services or what the President’s Commission designated as “adequate health care.” Clearly, these three levels are connected. A larger proportion of the GNP going to health permits coverage of more services. Similarly, as demonstrated by the end-stage renal disease program, providing specific services to a wider range of patients causes upward pressure on the proportion of the GNP going to health care and/or reduces the range of services covered as part of basic medical services. Despite these connections, these three levels are conceptually distinct.(Emanuel 1996:12)”

“The fundamental challenge to theories of distributive justice for health care is to develop a principled mechanism for defining what fragment of the vast universe of technically available, effective medical care services is basic and will be guaranteed socially and what services are discretionary and will not be guaranteed socially. Such an approach accepts a two-tiered health system- some citizens will receive only basic services while others will receive both basic and discretionary health services. Within the discretionary tier, some citizens will receive few discretionary services, and other richer citizens will receive almost all available services, creating a multiple-tiered system (Emanuel 1996:12).”

“Underlying the repeated failure of attempts to provide universal health care coverage in the United States is the failure to develop a principled mechanism for characterizing basic health services. Americans fear that is society guarantees certain services as “basic,” the range of services guaranteed will expand to include all-or almost all- available services (except for cosmetic surgery and therapies that have not been proven effective or proven ineffective). So rather than risk the bankruptcy of having nearly every medical service socially guaranteed to all citizens, Americans have been willing to tolerate a system in which the well insured receive a wide range of medical services with some apparently basic services uncovered; Medicare beneficiaries receive fewer services with some discretionary services covered and some services that intuitively seem basic uncovered; Medicaid beneficiaries and uninsured persons receive far fewer services (Emanuel 1996:12).”

“On this view, the reason the United States has failed to enact universal health coverage is not primarily political or economic; the real reason is ethical- it is a failure to provide a philosophically defensible and practical mechanism to distinguish basic from discretionary health care services. What is the reason for this failure of medical ethics?(Emanuel 1996:12).”

“There are two opposing explanations. One explanation points to the inherent limits of ethics. Some philosophers, such as Amy Gutmann and Norman Daniels, argue that we lack sufficiently detailed ethical intuitions and principles to establish priorities among the vast array of health care services. Every time we try to define basic services our intuition “runs out.” As Gutmann once wrote:

I suspect that no philosophical argument can provide us with a cogent principle by which we can draw a line within the enormous group of goods that can improve health or extend life prospects of individuals . . . The remaining question of establishing a precise level of priorities among health care and other goods is appropriately left to democratic decision-making1

(Emanuel 1996:12).”

“Taken at face value, this moral skepticism is extremely dangerous; it suggests that there can be no principled mechanism to define basic health care services and, therefore, that the efforts to ensure universal access will always founder on the fear that guaranteeing any health care to all citizens means guaranteeing all available services. It suggests we should just give up on a just allocation of health care resources because we can never succeed (Emanuel 1996:13).”

“The second explanation holds the problem with definining basic health care services is not a general lapse of ethics, but a specific lapse of liberal political philosophy that informs our political discourse, including the allocation of health care resources. The problem is that priorities among health care services can be established only by invoking a conception of the good, but this is not possible within the framework of liberal political philosophy. Liberalism divides moral issues into three spheres: the political, social, and domestic. It then holds that within the political sphere, laws and policies cannot be justified by appeals to the good. To jusify laws by appealing to the good would violate the principle of neutrality and be coercive, imposing one conception of the good on citizens who do not necessarily affirm that conception of the good. But without appealing to a conception of the good, it is argued, we can never establish priorites among health care services and define basic medical services. This is Dan Callahan’s view with which I agree:2

. . . there can be no full discussion of equality in health care without an equally full discussion on the substantive goods and goals that medicine and health care should pursue . . . [U]nless there can be a discussion of the goals of medicine in the future as rich as that of justice and health has been, the latter problem will simply not admit of any meaningful solution (Emanuel 1996:13).”

[In his controversial article entitled "Terminating Life-Sustaining Treatment of the Demented," Dan Callahan (Callahan 2001:93) claimed that euthanasia is necessary for patients suffering from terminal illness. Opponents claim that euthanasia is immoral and violates reason.]

“Fortunately, many including many liberals, have come to view as mistaken a liberalism with such a strong principle of neutrality and avoidance of the public good. Some think the change a result of the critique provided by communitarianism; others see it as a clarification of basic liberal philosophy. Regardless, a refined view has emerged that begins to overlap between liberalism and communitarianism. This overlap inspires hope for making progress on the just allocation of health care resources. This refined view distinguishes issues within the political sphere into four types: (1) issues related to constitutional rights and liberties; (2) issues related to opportunities, including health care and education; (3) issues related to the distribution of wealth such as tax policies; and (4) other political matters that may not be matters of justice but are matters of common good, such as environmental policies and defense politicies. While there still may be disagreement about the need for a neutral justification for rights and liberties, there is consensus between communitarians and liberals that policies regarding opportunities, wealth, and matters of the common good can only be justified by appeal to a particular conception of the good. As Rawls has put it:

Public reason does not apply to all political questions but only to those involving what we may call “constitutional essentials.”3 (Emanuel 1996:13).”

More expansively, Brian Barry has written:

Examples of issues that fall outside [the principle of neutrality include] two distinct kinds of items. One set of items (tax and property laws) contains matters that are in principle within the realm of “justice as fairness” but are subject to reasonable disagreement about the implications of justice . . . The other set . . . contains issues that in the nature of the case cannot be resolved without giving priority to one conception of the good over others . . . There is no room for a complaint of discrimination simply on the ground that the policy by its nature suits those with one conception of the good more than it suits those with some different one. This is unavoidable.4 (Emanuel 1996:13).”

“Thus it seems there is a growing agreement between liberals, communitarians, and others that many political matters, including matters of justice- and specifically, the just allocation of health care resources- can be addressed only by invoking a particular conception of the good (Emanuel 1996:13).”

“We may go even further. Without overstating it (and without fully defending it) not only is there a consensus about the need for a conception of the good, there may even be a consensus about the particular conception of the good that should inform policies on these nonconstitutional political issues. Communitarians endorse civic republicanism and a growing number of liberals endorse some version of deliberate democracy. Both envision a need for citizens who are independent and responsible and for public forums that present citizens with opportunities to enter into public deliberations on social policies (Emanuel 1996:13).”

“This civic republican deliberative democratic conception of the good provides both procedural and substantive insights for developing a just allocation of health care resources. Procedurally, it suggests the need for public forums to deliberate about which health services should be considered basic and should be socially guaranteed. Substantively, it suggests services that promote the continuation of the polity- those that ensure healthy future generations, ensure development of practical reasoning skills, and ensure full and active participation by citizens in public deliberations- are to be socially guaranteed as basic. Conversely, servuces provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia [13] [In his controversial article entitled "Terminating Life-Sustaining Treatment of the Demented," Dan Callahan (Callahan 2001:93) claimed that euthanasia is necessary for patients suffering from terminal illness. Opponents claim that euthanasia is immoral and violates reason]. A less obvious example is guaranteeing neuropyschological services to ensure children with learning disabilities can read and learn to reason (Emanuel 1996:14).”

“Clearly, more needs to be done to elucidate what specific health care services are basic; however, the overlap between liberalism and communitarianism points to a way of introducing the good back into medical ethics and devising a principled way of distinguishing basic from discretionary health care services. Perhaps using this progress in political philosophy we can address Dan’s challenge, begin to discuss the goods and goals of medicine (Emanuel 1996:14).”

References

Callahan, Dan. 2001. “Terminating Life-Sustaining Treatment of the Demented.” Bioethics Ed. John Harris. New York: Oxford University Press. p. 93.

Gutman, Amy. 1981. “For and Against Equal Access to Health Care.” Milbank Memorial Fund Quarterly. 59:542-60.

Emanuel, Ezekiel J. 1991. The Ends of Human Life. Cambridge, Mass: Harvard University Press. Chapter 4.

Norman Daniels , Ezekiel J. Emanuel , Bruce Jennings. 1996. “Is Justice Enough? Ends and Means in Bioethics.” The Hastings Center Report. 26.

Rawls, John. 1993. Political Liberalism. New York: Columbia University Press. p. 214.

Barry, Brian. 1995. Justice as Impartiality. New York: Oxford University Press. pp. 144-145.

Emanuel, Ezekiel J. 1996-11/12. “Where Civic Republicanism and Deliberative Democracy Meet.” Hastings Centre Report. November-December.

Beauchamp, Dan E.; Steinbock, Bonnie. 1999. New Ethics for the Public’s Health. Oxford University Press.

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