Ethical Issues in Infectious Disease Control Workshop 22nd of April – Centre for Professional Ethics, Keele University.

The Centre for Professional Ethics at Keele like to announce a Wellcome Trust funded workshop to be held at Keele University on the 22^nd of April focusing on the ethical issues raised by infectious disease control.

Abstract:

The outbreak of a new infectious disease, or a new variant of an old one, creates a new public health problem, as we have seen with both H1N1 (“Swine Flu”) and MRSA. Consideration must be given to what steps can be taken to stop, or at least slow, the spread of the disease. In addition to this scientific question, a number of ethical questions need to be addressed: What steps, if any, should be taken in an attempt to stop or slow the spread of the disease? What are the factors that need to be taken into account if we are to answer this question? What is the relevant balance between prevention and treatment? Where resources are scarce how ought they to be distributed? In an emergency situation, can traditional ethical concerns be ignored or overridden? Given the speed with which infectious diseases can spread there is often considerable time pressure, as we have seen in the case of H1N1, to quickly identify and implement an appropriate policy. This pressure can mean that there is little opportunity to deal adequately with these areas of ethical concern at the time.

Whilst uncertainties about how widely and quickly a new disease will spread mean that some of these questions are particularly difficult in the case of both new diseases and new variants of old ones, the questions themselves are not new. Very similar ethical issues are also raised in the context of treating infectious diseases that are better understood. In many cases, they have their roots in issues that are common to a wide range of such diseases. While these have been investigated and debated in some detail in relation to particular diseases, such as tuberculosis, the common themes that unite them (and the factors that affect how they play out) have not been much investigated by medical ethicists. As a result the lessons learnt in assessing the ethical acceptability of policies for dealing with one disease are not always transferred effectively to similar policies when these are suggested for dealing with other diseases. When a new disease, or new variant of an old one, appears this means that there is no readily available framework for considering the ethical questions raised by policies to deal with it, creating in turn a delay in responding to those questions. By bringing together philosophers, public health practitioners, ethicists and lawyers, this workshop will both further understanding of the ethical issues raised by particular policies in dealing with infectious disease, and provide the beginnings of such a framework for thinking about new conditions as they arise.

Speakers:

Professor Soren Holm, School of Law, Manchester University

Dr Heather Draper, Centre for Biomedical Ethics, University of Birmingham

Dr Sarah Damery, Department of Primary Care Clinical Sciences, University of Birmingham

Dr Alena Buyx, Assistant Director. Nuffield Council for Bioethics

Dr Michael Millar, Consultant Microbiologist, Department of Pathology & Microbiology, Barts & The London NHS Trust, Royal London Hospital

Dr Stephen John, Department of History and Philosophy of Science, Cambridge University

Dr Angus Dawson, Centre for Professional Ethics, Keele University, Editor of Public Health Ethics

Dr John Coggon, School of Law, Manchester University.

Dr Tom Walker, Centre for Professional Ethics, Keele University

Details:

Participation in the workshop is free of charge thanks to the funding of the Wellcome Trust – however places are limited so please apply promptly. If you would like to reserve a place please email Dr Tom Walker at t.walker@peak.keele.ac.uk

The workshop will run from 10.00 to 17.30 on Thursday 22^nd April 2010, and will be held in The Moser Centre at Keele University.

Information about getting to Keele can be found at: http://www.keele.ac.uk/aboutus/howtofindus/

The Centre for Professional Ethics at Keele:

Keele’s Centre for Professional Ethics (also known as PEAK – Professional Ethics at Keele) is amongst the largest and most successful providers of postgraduate ethics courses in Europe, with a portfolio of five distinctive MA / PgDip programmes as well as the UK’s first Professional Doctorate in Medical Ethics

In addition to this workshop we are holding a training day on ethical issues in infectious disease control for professionals working in the field of public health and other relevant areas on the 10^th of June – for further details see here: http://www.keele.ac.uk/depts/pk/news/KT-events/10.06.10.bookingform.pdf

Further details of the Centre can be found here: http://www.keele.ac.uk/depts/pk/

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New Journal of Medical Ethics Blog

The Journal of Medical Ethics has decided to join the blogosphere with a new Journal of Medical Ethics Blog which can be found here: Journal of Medical Ethics Blog

Medical ethics is a fast moving field where there is always some new scientific or political development to analyse and discuss.

It is difficult for a journal like the Journal of Medical Ethics (JME) to keep up with these day to day developments in its print version, but we hope to do it in this blog.

In the future we will bring you a range of posts:

1. Our own musings on all things ethical
2. Quick reviews of the most important new books as they appear and some old books before they disappear
3. Reports from interesting and not so interesting conferences
4. News about what the JME is doing and about interesting ethics papers in the JME’s sister journals

The contributors will be myself, Iain Brassington from Manchester University and Soren Holm from Cardiff University. Hope to see you over there at some point, as well as over here.

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The International Society for Priorities in Health Care 08 Conference

Call for Abstracts: Opens Jan. 31, 2008

The International Society for Priorities in Health Care invites you to submit an abstract to the 2008 conference to be held in Newcastle-Gateshead, UK - one of the
most beautiful, historic and diverse regions in the United Kingdom.

The conference provides a forum for researchers, practitioners, decision-makers and policy-makers to exchange ideas and experience. The Society focuses on getting research into practice by encouraging practitioners to learn about approaches to priority setting and encouraging researchers to learn from real experience across the spectrum of developing and developed nations.


This year's conference theme is "Managing scarcity in health care: theory-to-practice and practice-to-theory". Conference goals are to:

* Achieve participation from practitioners at all levels of health care (from international through to local) as well as the public
* Create a vibrant environment for two-way learning, from theory to practice and practice to theory
* Enhance learning about managing scarcity in more equitable and efficient ways, and thus, for the greater benefit of the population we serve.

Conference 28-31 October 2008

Details here: health priorities conference

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CFP: 9th World Congress of Bioethics

The 9th World Congress of Bioethics organized by the International Association of Bioethics will be held in Rijeka, Croatia September 5-8, 2008 with satellite conferences scheduled on September 3-4, 2008.

Abstracts are due January 31, 2008.

Further information about the Congress, the abstract submission process, and registration information is available at the Congress website

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On the 'Specialness' of Health Care

Shlomi Segall, in an article published in the September 2007 edition of the Journal of Political Philosophy, takes aim at Norman Daniels account of the specialness of health care. He gives a run down of what he takes to be Daniels’ view, and then proceeds to make some criticisms of the view from within Daniels’ own framework. In what follows I will show that while Segall succeeds on some accounts, he fails on others in such a way that the conclusion he reaches is deeply flawed.Segall challenges the equal opportunity account best elucidated in Daniels’ book “Just Health Care” and expanded upon in other books and articles. Segall is not interested in challenging the equal opportunity account per se, but is rather more interested in showing that the account doesn’t give us a good reason to think that health care is special (by ‘health care is special’ it is meant that “health care resources should be allocated in isolation from the distribution of other social goods”). The view that health care is special is what does most of the work for those who claim that health care should be allocated to people across the board, regardless of financial ability to pay for it. The ‘specialness’ claim allows for a loose lexical ordering of health care resources in front of resources spent on other social goods. It is distinct, however, from a view that considers health care to be the most important social good, which would commit us to the maximization of the allocation of all resources to health care, essentially prohibiting any allocation whatsoever from other social goods like food, housing, education, etc.

Daniels’ equal opportunity account, roughly outlined, is that health care is a necessary social good for human beings to be able to live out and pursue their life plans. Since the only way someone could have the ability to pursue their life plans is if they are found within a certain ‘normal opportunity range’ (the range of normal opportunities one has within a particular society, relative to ones talents) and a reasonable level of health is required for the normal opportunity range to mean something, we have an obligation to ensure a reasonable level of equal health care that would allow for an appropriate restoration of health to that normal opportunity range. Segall first takes aim at the idea that health is necessary to pursue ones life’s plans. This is one area where I think Segall’s criticism of Daniels stands. In brief, Segall argues that it is not worth spending significant health care resources on the life plans of senior citizens, all things considered. Yet it is consistently the case that health care for senior citizens in the twilight of their lives is placed at par with or even over and above that of people early in their lives, the time in which they are still in the process of determining what their life plans even are. In fact, the health care of seniors accounts for significant portions of health care expenditures in most advanced industrialized nations. The often-cited figure for the US is that 30% of health care expenditures are spent in the last six months of life, and of course, much of those monies are spent on seniors. While Daniels makes allowances for a dropping of health care expenditures for patients over the age of 75, the strength of Segall’s criticism is found in the fact that the specialness account of health care means that health care is special across the board, not just for those who still have life plans. Segall notes in a footnote that this criticism can be leveled against Daniels with regards to anyone who has completed (forcibly or not) their life plans but is still alive, such as a convicted serial murderer on death row. It seems then that is Segall is right (and I think he is), that health care expenditures are not justified for seniors if what justifies health care expenditures in the specialness account is the fact that normal opportunity range is required to carry out ones’ life plans. Senior citizens, most of us would agree, while important parts of society, are certainly not in the process of creating their life plans – most are, in fact, finishing up their life plans. Yet this doesn’t capture current health care spending practices nor does it capture our deep seeded intuitions about care for the elderly, nor can it properly account for why seniors are entitled to a share of health care resources despite their inability to pay.

Segall suggests a way around this problem, a way I intend to explore in more depth in my thesis itself. He suggests that rather than trying to justify his appeal to the specialness of health care by way of Rawls’ Fair Equality of Opportunity Principle, he ought to try to go through Rawls’ Difference Principle instead. For now I’d like to skip past this suggestion and move on to where I think Segall went wrong.

Using Dan Brock as ammunition (I have previously argued in a similar vein against Brock, though there are revisions on that argument to come, thanks to Colin Farrelly), Segall argues correctly that “differences in health are determined primarily by factors other than health care and most significantly by socio-economic factors… To be clear: by ‘socio-economic factors’ it is meant socio-economic factors that affect health directly, independently and apart from socio-economic factors that affect access to health care.” He continues, saying that “there is strong indication that health care is not nearly as significant in determining our health as was once thought.” In short, socio-economic factors have the most effect on health prior to health care. Daniels would agree with this assessment, though there is an underlying assumption that I think Daniels (and certainly I) would not agree with.

It is true that socio-economic factors affect health more directly than they affect health care, however, this does not preclude socio-economic factors from having a nontrivial indirect effect on the delivery of health care. Segall alludes to this objection, though he never explicitly engages it. Instead, he engages the objection that non-clinical public health concerns indirectly affect health and proceeds to show that if they are allowed within the purview of health care they will mean we will have to expend precious resources on things that don’t look much like health care, like enforcing cleanliness requirements at supermarkets and ensuring that restaurants meet a certain level of health safety standards. These indirectly affect health, but not in a way that could rationally construed as health care, or even in a way that an effective argument could be mounted for their inclusion in spending designated specifically for health care. But this objection, (a fair one at that) doesn’t take into account the objection I raised to his exclusion of health care specifically because socio-economic factors do not have as direct an impact on health as they have on health itself. All it shows is that there are some factors that have an effect on health that we cannot classify as health care expenditures or that we cannot otherwise justify under the banner of health or health care. It doesn’t say anything about the indirect manner that socio-economic status can have on the delivery of health care itself, or more importantly, on access to health care. All Segall has established is that health is prior to health care with regards to the direct effects of socio-economic status. However, it could very well be argued that the indirect impact of socio-economic factors on health care is not displaced or rendered less important because of this fact. Just because these factors are shown to have a direct effect on health doesn’t get us off the hook for socio-economic injustices found in the health care system, even if they are produced indirectly. Moreover, health care is a response to poor health. While it is not the whole story of health (for instance, it cannot account for the issues of public health that were raised above), it is enough of the story of health that we can reasonably include it in discussions of health, and also, I contend, in discussions surrounding the manner to which socio-economic status affects health more generally.

Does Segall succeed in showing that because of the concessions Daniels has been forced to make (life plans, the impact of public health and education on health) he must abandon the specialness of health care resource allocation? Segall seems to think that yes, he does, saying, that “Daniels cannot meet the ‘social determinants’ objection by shifting focus from health care to health without thereby abandoning the allusion to specialness altogether.” But I think Segall is being too hasty when he claims that Daniels must move from health care to health because of this objection. Daniels is rightly forced to admit that health is important in the determination of health care resource allocation, a point that strikes me as somewhat trivial. But he is not forced to admit that because there is more than just health care involved in health – quite clearly, health care concerns a response to health deficiencies; when health deficiencies are the result of negative socio-economic factors, it is not especially hard to think that these factors may carry over into the treatment of health care deficiencies. The fact that a homeless person’s diet contributed to his malnutrition doesn’t mean that his poverty won’t have a noticeable effect on his ability to get treatment for his malnutrition, unless a system is in place that does not discriminate against his inability to pay for that treatment. Even if it turns out that the socio-economic factors play a more significant role in his diet than they do in his ability to pay for health care treatments, this does not mean that health care is neither important or special: To say that somehow health care is not affected by socio-economic factors because these factors are more noticeable at the level of general health seems to miss the entire point of having a health care need. While there is much to be said for preventative measures with regards to health, health care retains its specialness because when any person, disadvantaged or not, is in need of it, their quality (and quantity) of life is seriously jeopardized in such a way that they must rely entirely on the expertise of others to make it better (I’ve argued this point in particular here). Other social goods do not rely on the specific expertise of others in the same way. Showing that socio-economic factors are more influential at the higher more abstract level of health doesn’t right away imply that there are not other reasons that health care may be a special social good. Moreover, it doesn’t stop the theorist from arguing that socio-economic factors are transitive – that is, they don’t stop with direct effects, but are rather causally related in important ways with the way those direct effects are treated or dealt with (thus socio-economic factors will have both a direct and indirect effect on the distribution of health care resources). This will require empirical evidence, though I don’t think it is particularly difficult to see how ones income would determine their ability to access an expensive health care system if they were in the position of the homeless man that I described above and that health care system did not have a commitment to equality and universality of access. However, I’m not committing myself to this as it stands right now, for fear of being charged with begging the question.

ADDENDUM: Colin Farrelly, a political philosopher here at Waterloo who is on my thesis committee, has reached a different conclusion than I. To see his take on this article, see his post here.

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BlogWarBot

If you have ever had a frustrating political discussion with someone, where you just can't see eye to eye because you have completely different preconceptions, then you will know how these discussions can degenerate.

Sick and tired of getting involved in these sorts of discussions on blogs Chris Clarke developed the BlogWarBot an automated opponent to carry on these discussions for him. You can check out some of the resulting discussions here: Blogwars reconsidered
And engage in battle yourself here: BlogWarBot Very amusing.

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A good summary of theories of distributive justice

A good summary of theories of distributive justice by Lawrence B. Solum can be found here: Legal Theory Lexicon: Distributive Justice

Its a good summary which covers the basics well, the only complaint I would make about it is that there is no mention of luck egalitarianism. Still well worth directing people to as an introduction.

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The evil of big Pharma

Ben Goldacre appears to be running a series on how pharmaceutical corporations contribute to the high cost of health care in the Guardian: Evil ways of the drug companies Spectacularly expensive cost of trial and error

In this post I will discuss the first article where he gives three reasons for thinking that Big Pharma are unethical,

1.

They spent only 14% of that money on research and development, but 31% on marketing and administration. They are very careful not to let anyone see how much goes on marketing and on administration. Whenever you hear the drug companies explaining why they have to charge so much for their products - perhaps as they are denying their lifesaving Aids drugs to the 20 million HIV-positive people in Africa - the plea is that they need money to develop new drugs. That's not true if they spend twice as much on marketing as on research and development. This unhappy collision of facts makes them look very evil indeed.

2.

They also charge this money in slightly evil ways. Drugs have 10 years "on patent." Loratadine is an effective antihistamine drug that does not cause drowsiness. Before the patent ran out, the price of this drug, by Schering-Plough, was raised 13 times in the US in just five years, increasing by over 50%. This is not a price rise in keeping with inflation. This is evil.

3.

Me-too drugs are an inevitable function of research driven by a market: they are rough copies of drugs made by another company, but they are different enough for a manufacturer to claim its own patent.

They need to be tested and marketed just like a new drug; but for all that effort they generally don't represent a significant breakthrough in human health. They are merely a breakthrough in making money. Again, you have to admit, that is reasonably evil.

What Goldacre really seems to be reacting to is the running of pharmaceutical corporations as profit making companies. I'm happy to agree, there seems to be something troublesome about profit making from human misery, which inevitably is what Pharma companies are doing. But there is something powerful to the idea that we need profit making and taking to give incentives to take the risks inherent in developing new medication. I'm more inclined to think that what we need is a different incentive structures along the lines suggested by Pogge, rather than removal of pharma as profit making companies. Of course there is the bigger question as well, how much new medicine do we really need?

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Novartis loses India Patent case

This is almost certainly good news for those of us who are concerned about global justice, and the availability of medicine to those in the developing world. The New York Times reports in this article: Setback for Novartis in India Over Drug Patent

Novartis sought to determine whether an Indian court had been right to deny a patent on a modified form of the Novartis leukemia drug Gleevec, known in Europe and India as Glivec. The application was rejected on the grounds that the new drug was insufficiently different from the previous version.

In effect what the ruling does is uphold Indian law which prevents very minor 'innovations' or changes to an existing medication being used as a basis for a new patent application.

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Joining the IAB

In our recent recruitment drive several people asked for details of joining the International Association of Bioethics (IAB). I thought it would be good to have these here so details about the IAB and joining are below the fold.

The Association has the following educational and scientific objectives:

1. To facilitate contacts and the exchange of information between those working in bioethics in different parts of the world;
2. To organize and promote periodic international conferences in bioethics;
3. To encourage the development of research and teaching in bioethics;
4. To uphold the value of free, open and reasoned discussion of issues in bioethics.

You don't need to be a member of the IAB more generally to join the philosophy and bioethics network, although of course we encourage it. You can get details on joining the IAB more generally here: Join

It is a particularly good idea if you are going along to the IAB congress which happens every two years, since you get a discount which is usually more than the cost of membership. The next congress is in September 2008, in Croatia. Some details about the conference are in the latest newsletter. It is safe to say it is usually the largest bioethics conference in the world.

You might also be interested in some of the other IAB networks details of which are here: Networks

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Political interference with Health Care

It is unfortunate that this is unsurprising, but once again Bush's regime seems to be interfering with scientific reports in the name of politics. The recent accusations by the former Surgeon General are well detailed in this report: Bush Aide Blocked Report in the Washington Post.

Carmona told lawmakers that, as he fought to release the document, he was "called in and again admonished . . . via a senior official who said, 'You don't get it.' " He said a senior official told him that "this will be a political document, or it will not be released."

Steiger did not return a phone call seeking his comment. But he said in a written statement released by an HHS spokesman Friday that the report contained information that was "often inaccurate or out-of-date and it lacked analysis and focus."

Steiger confirmed that he sharply disagreed with Carmona on the issue of how much the report should promote Bush administration policies. "A document meant to educate the American public about health as a global challenge and urge them to action should at least let Americans know what their generosity is already doing in helping to solve those challenges," Steiger said in the statement.

Steiger said that "political considerations" did not delay the report; "sloppy work, poor analysis, and lack of scientific rigor did." Asked about the report's handling, an HHS spokeswoman said Friday that it is still "under development."

This seems amazing, if you read the actual draft of the report available here: draft report (Hat tip to Daily Kos) You will see that Carmona primarily relies on World Health Organisation figures and data, not renowned for their lack of scientific rigour. And the report seems sound, there is nothing radically wrong here. It sure looks like the regime trying to edit the science in the name of politics.

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Health Inequalities or Health Care Inequalities?

Much of the health care literature attempts to distinguish between health care and health. In my estimation, most of the literature (at least as I have read thus far) fails to properly distinguish between the two concepts and as a result, comes out with muddled or confusing takes on distributive justice and the health care problem. In this brief section, I will argue that if we take the call to properly distinguish health from health care, we find that health care remains as important as ever. In fact, the theorist who wants to take health seriously will find that in order to do so, she must not lose sight of the health care problem, and in particular, she must recognize that the health care problem is primarily about economic inequality.

The distinction between health and health care is quite difficult to make. Hoedemekers and Dekkers identify these difficulties in their paper “Key Concepts in Health Priority Setting”. They illustrate how much the definitions of health care and how these variations can affect the way health care planners and resource allocators make their decisions. In discussing the WHO definition of health (“health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”), the authors show that health is holistic in such a way that individual demand for any health care services based upon it cannot be realistically restricted. On the other hand, many, especially health practitioners, restrict health to the bodily dimension only. The focus is not found in total well being but rather in whether or not the biological functioning of the organism is in working order. The dichotomy between the two views can also be seen in the way the patient and the physician view the term ‘abnormality’. The patient will often associate normality with health and abnormality with disease, based solely on personal standards of reference. For example, the fact that the smoker is hacking up a lung may be normal, while the contraction of lung cancer is not. For the physician, however, the definitions are much more precise with the definition of ‘normality’ determined by empirical data used to establish an objective standard of biological function in an organism. Comparisons of diagnostic data with these statistical standards reveal abnormalities and thus, for the physician, that same smoker who thought he was normal, is abnormal.

We’ve all heard stories about hardened older men who refuse to go visit the doctor because they’ve always been healthy and think that the doctor is just out to cause them trouble. These people have one concept of what health means, while the annoying mother who takes her children in for every ache and sniffle has a different concept of what health is. So how do we navigate these waters, especially as we try to discover the best way to distribute scarce health care resources?

In a very interesting paper, Dan Brock argues that one of the biggest failures of bio-ethicists is that they have focused too much on the problems related to health care and not enough on the problems related to health. He argues that the application of distributive justice to health care neglects very important issues brought up by the very concept of health. One of the most important things, Brock argues, is that those concerned with distributive justice and health care ought to take seriously the need for prioritization of health care services and the inevitable health care rationing that does and will occur. By focusing on health care rather than health, bio-ethicists only handicap themselves by attaching themselves to a project with no end. Justice (implied to be some kind of equity among the distribution of resources) is just not possible; theorists would be better off focusing on the prioritization of health needs rather than health care needs.

In one important paragraph, Brock attacks the idea of a right to health care, arguing that it cannot properly account for the reality of rationing.

Moreover, specifying in detail what services the right encompassed, and in particular what services it did not encompass, smacked of and was easily attacked as rationing. Although most bio-ethicists recognized the unavoidability and even the desirability of rationing, few politicians did, at least openly, and in public and health policy debates one’s views were often an easy target for discrediting if they could be tarred with the label of rationing. The general public, irresponsibly encouraged by many politicians and physicians, preferred to believe that in a rich country like ours with such an important good as health care, rationing was not necessary and did not in fact occur. Of course, this perspective overlooked the rationing imposed on the uninsured, as well as on others, but somehow this cognitive dissonance survived widely. And, given the pervasive belief that rationing did not occur, was not necessary, was politically dangerous, and would be morally wrong if it did occur, serious public discussion of it and of the limits to the right to health care was unlikely, and in fact rarely occurred. All this was quite remarkable during a period, which continues to this day, in which cost containment was the dominant issue of health policy, since the most obvious means of controlling health care costs is to deny some people some care, that is to ration care. But the preference was to believe that, by such means as cutting the “waste, fraud, and abuse” out of the health care system, costs could be adequately controlled without rationing.

By ignoring prioritization and rationing, argues Brock, those bio-ethicists who have influence in the realm of public policy are contributing to this “cognitive dissonance” within the American population (note that Brock admits that many bio-ethicists recognize the unavoidability of rationing. They just have a tendency to ignore it). Indeed even Brock agrees that the greatest inequity in the health care system is the fact that 44 million Americans have no health insurance whatsoever. To Brock’s credit, he exposes the lie that cost-effectiveness and utilitarian calculi will be able to address the issues of prioritization properly. By focusing on a population as a whole, utilitarian calculations have a cold and cruel way of neglecting the needs of those who are worst off. Others argue that utilitarianism actually focuses more on those that are worse off because it sees the utility gains from those in the poorest health as contributing more to the over all utility of the population (Gandjour, Lauterbach, 2003). While compelling, this argument fails to take into account the fact that the worst off are also those who cannot afford to pay for any services rendered, and thus in order to focus on the improvement of those who are worst off, utility would decrease as resources are a key function of aggregate utility.

That said, Brock wants to question the focus on those who are worst off. It’s not that he doesn’t think those who are worst off deserve our care. They do. But, argues Brock, there are often situations in which providing care for someone who is dying of AIDS provide less benefit than expanding inadequate funding for nonfatal conditions like substance abuse or mental health disorders.

Before you have a heart attack, remember how I began this discussion. It is important to see that Brock is drawing a line in the sand between health care priorities and health priorities. Perhaps the AIDS patient is in need of a bone marrow transplant or some other treatment for a disease that will lead to his eventual death, a definite health care priority. But perhaps a drug addict is seeking help in a facility, looking to get off the street. If one looks at health in a holistic sense, a dilemma becomes quite clear. Where do limited resources go? What justifies their allocation? Or, alternatively, suggests Brock, what reasons do we have to give priority to the worst off? Who are the worst off? How much priority should they receive in health care prioritization?

As Hoedemekers and Dekker suggest and Brock agrees with, the more expansive your definition of health, the more resources will be necessary. And unfortunately, the more resources needed, the more justification will be needed for prioritizing those who are worst off.

This brings us to a second issue for Brock. This concerns the socioeconomic factors laden in the health care issue. The question is really one of chicken and egg, as far as I can tell. It’s well documented that socioeconomic factors have an influence on the ability to obtain health care and more dangerously, poor socioeconomic status has a negative effect on the health of an individual. What’s more difficult to show is that poor health has an effect on socioeconomic status (Hausman, Asada, Hedemann, 2002; Brock 2000). The key thing to note is this: by focusing on health care rather than on health, bio-ethicists have neglected the links and ties of health to socio-economic factors that surround health. Brock writes, rather forcibly,

More important, inequalities in health among individuals and groups that are within human and social control are not primarily the result of inequalities in access to or use of health care. This is not to deny, of course, that medical care is often of great importance for the life and well-being of individual patients. But differences in access to and use of health care have only a negligible effect on health inequalities among social groups, in particular individuals of different socioeconomic classes. The crucial point is that differences in the incidence of illness and injury from social causes swamp the effects on health of differences in access to and use of medical care to treat that illness and injury (Wilkinson 1996). So if inequalities in access to health care are of moral concern because they result in inequalities in health, then focusing on health care will miss most of the action on the real matter of concern—health and health inequalities.

Now this may cause the reader to question the focus on the health care system, thinking that those concerned with distributive justice and health care must instead focus on the inequalities found in health rather than on health care. However, I don’t think this shift should happen that fast. In another section, Brock unwittingly gives us a clue as to why. He writes,

Higher societal income inequality adversely affects citizens’ health and life expectancy; for example, infant mortality and death rates of the lowest social classes in Sweden, which has low inequality in income, are lower than those of the highest social classes in England and Wales, which have much less egalitarian income distributions (Wilkinson 1996). So there are at least two important social determinants of health at work, where one stands in the socioeconomic hierarchy affects one’s health, and the degree of income inequality in a society affects the society’s overall level of health and health inequality. If the effects of poverty and inequality are combined, even in a rich country like the United States, the size of the impact is striking. In the U.S. the difference in age-adjusted mortality between metropolitan areas with the combination of high inequality and low per capita income and those with low inequality and high per capita income is greater than the combined loss of life from lung cancer, diabetes, motor vehicle crashes, HIV infection, suicide, and homicide (Lynch et al. 1998).

So it turns out that economically unequal societies have greater incidences of health inequality, and more importantly, the negative effects from economic inequality are greater than the negative effects of negative health. Not only does one’s place on the socioeconomic ladder determine health, but so does the overall degree of income inequality in that society.

If we remember back to a post I wrote a few days ago and something I alluded to at the beginning of this post, health care is primarily an economic problem. Unlike normal products, it involves an individuals well being, the commodification of knowledge and an undesired state of being that needs to be rectified. It is precisely the commodification of health inequality that makes health care an economic issue. Brock is right – a greater focus on health inequalities will broaden the agenda of the bio-ethicist and show her that not only does the definition of health matter, but so do the economic inequalities found in the social system as a whole. I think that Brock answers his own questions though he fails to see the answer supplied by his own arguments. Focusing on health, coming to the recognition that prioritization and health care rationing in inevitable, and understanding that economic inequalities in the system itself contribute to poor health is precisely why theorists should pay attention to the health care system and not simply health as a general idea. Not only is the concept of health contentious, broad and open to interpretation, but it doesn’t deal with the currency of care – money. When a theorist interested in justice, and in particular justice for the worse off, finds herself interested in the health question, she ought to turn her attention primarily to health care inequalities over health inequalities. The maximization of resources in a way that takes rationing into account and pays attention to the worse off, while recognizing all the external socioeconomic factors involved will go a lot further towards achieving economic equality than will theorizing about an ill-defined and subjectively interpreted category of human existence.

References:

Brock, Dan. (2000) Broadening The Bioethics Agenda. Kennedy Institute of Ethics Journal. 10: 21-38.

Gandjour, Afschin; Lauterbach, Karl. (2003) Utilitarian Theories Reconsidered: Common Misconceptions, More Recent Developments and Health Policy Implications Health Care Analysis 11: 229-244.

Hausman, Daniel M et al. (2002) Health Inequalities and Why They Matter. Health Cara Analysis 10: 177-191.

Hoedemaekers, Rogeer; Dekkers, Wim. (2003) Key Concepts in Health Care Priority Setting. Health Care Analysis 11: 309-323.

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Introducing Myself

I thought that before I make any substantive posts I should introduce myself and give a little background into who I am and the research I am currently doing. I'd like to thank David for asking me to join this blog, and I look forward to contributing positively here. I am an M.A. student in philosophy at the University of Waterloo in Waterloo Ontario, Canada. My primary interests are in political philosophy, ethics and applied ethics, and I am currently in the process of writing my M.A. thesis under Dr. Brian Orend, a noted human rights scholar and just war theorist. I blog regularly on matters political, philosophical and religious at Dinner Table Donts.

The posts linked to by David explore arguments I have encountered while preparing to write my thesis. I am working on the defense of a universal and equal health care system with an appeal to human rights theory. I am particularly interested in how human rights can help a society maintain a more egalitarian system of distributive justice when it comes to health care, all the while being sensitive to the issues of resource allocation, health care rationing and the reality of economics. Many of the knock down arguments concerning the application of human rights theory to the health care problem come from the thought that viewing health care as a human right necessarily commits a society to an unreasonable financial burden. I am looking not only to defend human rights theory against this objection, but also to show that an appeal to human rights is the only way to ensure that a society will appropriately value health care as equal and universal, without discrimination by socio-economic status, race, age or sex.

I look forward to posting arguments, thoughts, comments and linking to articles that may be of interest to those who read this blog. I'm also looking forward to constructive criticism on any and all posts that I write, as I have found that criticism is typically more valuable to me than praise.

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New Contributor: Peter Thurley

We are happy to announce we have a new contributor joining us from Canada, Peter Thurley who writes the blog: Dinner Table Donts.

Peter has already written about ethical issues in resource allocation with three fascinating posts:
1. What's so special about health care
2. Why Equal Opportunity is not Enough
3. Consequentialism and the Tragedy of Economics

I look forward to reading and discussing what he has to say here. Both this blog and Philosophy and Bioethics are still looking for more contributors so please email me if you are interested.
Cheers
David

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How to fix health care? Start with med schools

Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention has argued that the way to fix health care is to start with the med schools today in MSNBC.

Gerberding focuses on the suggestion of more professionals being trained and more cross over between medical professions in training so that they can do this effectively in the field. I'd also suggest (as I have argued in a forthcoming paper in the Journal of Medical Ethics Am I my Brothers' Gatekeeper? Professional Ethics & the Prioritisation of Health Care) that what is needed is explicit training in the ethics and justice of health care prioritisation. If health care professionals believe it is ethically unacceptable to ever prioritise between patients then any prioritisation scheme is doomed to fail, regardless of whether it is actually consistent with their professional ethics. This requires a considerable program of education for present health care professionals and a revision of much of the training provided for new health care professionals, to get them to recognize both the scarcity of health care resources and the compatibility of prioritisation of these resources with the professional ethics of health care professionals.

Of course what is also needed is a fair background system of health care distribution, something America seems to be sadly lacking presently.

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Pricing Pills by the Results

Interesting article in the New York Times on pricing pills by their results. The basic idea is rather than pricing the drugs on cost + profit, they will be paid for only if they are actually beneficial for particular patients. In principle this means the drug company shares the risk with the purchaser. This has been suggested to the UK National Health Service by Johnson & Johnson in relation to one of their cancer drugs.

While I like the principle, I am not convinced that this will genuinely save money, since logically the pharma companies will have to raise their prices to ensure that they are still profitable. This may allow for more drugs to be tried, which ought to increase efficiency. However this could place increased pressure on National Health Services to provide coverage for far more marginal and very expensive drugs for the few patients they are effective for, regardless of their cost effectiveness.

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Comparing US Presidential Candidates on Health

Susan J. Blumenthal, M.D., Jessica B. Rubin, Michelle E. Treseler, Jefferson Lin, and David Mattos have created a very useful site: U.S. Presidential Candidates' Prescriptions for a Healthier Future: A Side-By-Side Comparison.

As you might imagine from the name this provides both a discussion of, and charts of and links to the positions of presidential candidates on health care. If you want a one-stop shop summary of their views on health care, this is the place to go.
(Hat tip to Women's Bioethics Project)

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Should rapid tests for hiv infection now be mandatory during pregnancy? global differences in scarcity and a dilemma of technological advance

An excellent paper by Charles B. Smith, Margaret P. Battin, Leslie P. Francis & Jay A. Jacobson on the ethical issues in mandatory HIV testing during pregnancy can be found in the latest edition of Developing World Bioethics.[1]
Abstract and discussion below the fold.
Abstract:

Since testing for HIV infection became possible in 1985, testing of pregnant women has been conducted primarily on a voluntary, ‘opt-in’ basis. Faden, Geller and Powers, Bayer, Wilfert, and McKenna, among others, have suggested that with the development of more reliable testing and more effective therapy to reduce maternal-fetal transmission, testing should become either routine with ‘opt-out’ provisions or mandatory. We ask, in the light of the new rapid tests for HIV, such as OraQuick, and the development of antiretroviral treatment that can reduce maternal-fetal transmission rates to <2%, whether that time is now. Illustrating our argument with cases from the United States (US), Kenya, Peru, and an undocumented Mexican worker in the US, we show that when testing is accompanied by assured multi-drug therapy for the mother, the argument for opt-out or mandatory testing for HIV in pregnancy is strong, but that it is problematic where testing is accompanied by adverse events such as spousal abuse or by inadequate intrapartum or follow-up treatment. The difference is not a ‘double standard’, but reflects the presence of conflicts between the health interests of the mother and the fetus – conflicts that would be abrogated by the assurance of adequate, continuing multi-drug therapy. In light of these conflicts, where they still occur, careful processes of informed consent are appropriate, rather than opt-out or mandatory testing.

Smith et al make the excellent point that:

it is crucial to recognize that a person with a communicable infectious disease is both victim and vector at one and the same time, a person who is both the recipient of infection from someone else and a potential infector of another party. An ethically adequate policy in any context must recognize this fact – even in conditions of scarcity or extreme scarcity, which make it impossible to satisfy fully our social, legal and moral obligations to persons in both these roles. Policies mandating HIV testing in pregnant women typically treat the mother as vector and the child, to whom she might transmit HIV, as potential victim, but they sometimes neglect to see that the pregnant woman is also a victim, the recipient of HIV transmission from someone else, a person in medicalneed. An ethically adequate policy must see her in both these roles.

It is an excellent article which does a good job of balancing justice, the ethical considerations and the situation in the real world. Well worth the read.

[1]Charles B. Smith, Margaret P. Battin, Leslie P. Francis, Jay A. Jacobson (2007)
should rapid tests for hiv infection now be mandatory during pregnancy? global differences in scarcity and a dilemma of technological advance
developing world bioethics 7 (2), 86–103.

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Philos-L Email list RSS Feed

Philos-L is perhaps the most active philosophy email list. It is the place to subscribe to if you want to hear the latest that is happening in the job market (especially the UK) and with conferences etc. You can sign up to the Philos-L list here: Philos-L
However a fair number of people don't subscribe to it, both because of it's busyness and also because of the occasional 'discussions' that break out there. One way to deal with this is by setting the list to send you out a once daily digest which you can do here: Philos-L settings. Another way to work around this is explained below the fold.

The problem with the traditional digest mode is that you still have to sift through the stuff you don't want to get to read the stuff you do. I've been reading around recently about some people who are no longer reading their email, they are instead forwarding it to a website which converts it into an RSS feed. They can then select which items they want to read at a glance. A light bulb went on, why not do the same thing with the Philos-L list for those people who don't want to subscribe to the emails themselves? It took a fair bit of mucking about using Yahoo Pipes and a few other tools but I've finally managed it. So if you have a personalised home page or a feed reader as I discussed in A motherlode of your very own then you can now add the RSS feed of the Philos-L list to your reader if you want. You can get the feed here: Philos-L RSS feed
Of course I have already added it to the Motherlode.

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Responsibility for Health

The bioethics forum has an interesting round up of the political divisions in regards to responsibility for poor health by Harald Schmidt, Assistant Director of the Nuffield Council on Bioethics.

Schmit is broadly critical of the classic left/right division in regards to personal responsibility. Given my luck egalitarian leanings it will probably be unsurprising that I broadly agree. Both the left and the right need to take into consideration personal responsibility, of course how this ought to be done is a tricky question, especially given the epistemic difficulties in determining responsibility.

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