Transcript Should medical care be withheld from those individuals

Should medical care be
withheld from those
individuals that have made
"poor lifestyle choices"?
(Managed Care)
Colin Sherrill
Andy Von Canon
BINF 705
Approach
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Background
Definitions and Analysis
Viewpoints & Perspective
Ethical Implications
Conclusions
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Pro
Con
Decision
Reality
Background/Why
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Very Complex Problem – One of the most discussed areas of ethics
Most ethics discussions avoid the Patient Responsibility from the patient’s
viewpoint
Diabetes
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Type 1, Autoimmune disease
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Type 2, Acquired
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The immune system attacks the insulin-producing beta cells in the pancreas and
destroys them.
Type 1 diabetes accounts for about 5 to 10 percent of diagnosed diabetes in the
United States.
It develops most often in children and young adults, but can appear at any age.
This form of diabetes is associated with older age, obesity, family history of
diabetes, previous history of gestational diabetes, physical inactivity, and
ethnicity.
About 80 percent of people with type 2 diabetes are overweight.
Type 2 diabetes accounts for 90 to 95 percent of diagnosed diabetes in the
United States.
The symptoms of type 2 diabetes develop gradually. Their onset is not as sudden
as in type 1 diabetes.
This is interesting for a few reasons
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This is not necessarily a lifestyle choice.
A social stigma exists for this disease complicating decisions about research.
Does it matter howhttp://chinese-school.netfirms.com/diabetes-types.html
one acquires a disease?
Smoking
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The risks of smoking
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Slipping down the slope
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Smoking up to the time of any surgery increases cardiac and pulmonary complications,
impairs tissue healing, and is associated with more infections and other complications at the
surgical site.
Acquire lung, throat, and other cancers.
“Smoking is, however, unique in that its associated risk can be reduced substantially within a
short period.” -Matthew Peters
Enjoying a cigarette before the operation could suck money out of the healthcare system –
and thereby worsen someone else’s treatment.
thetruth.com lists many risks associated with smoking.
In 2006, a UK primary care trust announced that it would remove smokers from its surgery
waiting lists to cut costs.
Should we deny medical attention to many people with other bad habits?
“Do patients have a general obligation to get healthy as a condition of receiving treatment?
Patients are not required to visit fitness clubs for eight weeks, lose 25 pounds, or take drugs
to lower blood pressure before surgery.” -Leonard Glantz
What about alcoholics, drug users, etc? Should everyone be screened for every bad habit
before surgery?
Listening to your doctor
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Before surgery, you don’t drink water, take your pills, don’t drink alcohol. Where does their
authority end? When do “doctor’s orders” become “doctor’s advice?”
We do accept a certain amount of responsibility before surgery, as we ought to.
http://www.newscientist.com/blog/shortsharpscience/2007/01/do-smokers-deserve-equal-medical-care.html
STDs
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There are numerous medical risks associated with a promiscuous lifestyle.
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Chlamydia, HIV, HPV, Herpes, Gonorrhea, Hepatitis, Syphilis, etc.
Constantly educated about them.
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Statistics
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DARE, AdCouncil, Sex Ed.
One in five people in the United States has an STD.
More than half of HIV infections occur in people under 25. Does the education work?
Two-thirds of all STDs occur in people 25 years of age or younger.
One in four new STD infections occur in teenagers.
Cervical cancer in women is linked to HPV.
STDs, other than HIV, cost about $8 billion each year to diagnose and treat ASHA is a
trusted partner with the Centers for Disease Control and Prevention and operates the
national AIDS, STD and Immunization Hotlines.
One in five Americans have genital herpes, yet 90 percent of those with herpes are unaware
they have it.
At least one in four Americans will contract an STD at some point in their lives.
Where is the responsibility?
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How much money should go to educate the public? How much to treat the diseases? How
much to research?
If these diseases were passed some other way, would that make a difference?
http://www.coolnurse.com/std2.htm
Obesity
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Prevalence.
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Problems
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Approximately 127 million adults in the U.S. are overweight, 60
million obese, and 9 million severely obese.
Currently, 64.5 percent of U.S. adults, age 20 years and older,
are overweight and 30.5 percent are obese.
Obesity increases the risk of illness from about 30 serious
medical conditions.
Obesity is associated with increases in deaths from all-causes.
Ethics
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Weight loss of about 10% of body weight, for persons with
overweight or obesity, can improve some obesity-related medical
conditions including diabetes and hypertension.
Does this mean that the obese are responsible for part of their
health related issues?
http://www.obesity.org/subs/fastfacts/Health_Effects.shtml
Money
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Ought money even influence our ethical decision?
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Does the correct thing to do depend on the cost?
That is generally how we live our lives anyway, so it ought to be
considered.
Healthcare costs
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Dr. Jeffery Burnich said, “To help lower your health costs, promote
wellness programs.”
The most effective “wellness programs” are:
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Stress management, weight management, physical fitness, nutrition, medical
self-care, and smoking cessation.
Smokers generate 31% higher claim costs than nonsmokers.
Medical expenditures were $1.4 trillion in 2000, and are expected to
reach $2 trillion in 2010. Should we focus on lowering this number?
Deciding what money goes where is a big question.
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It is an ethical question to determine how to distribute money among
research, treatment, wellness programs, advertising, and money for
bioinformatic graduate students.
http://www.ncpers.org/PastConf/2003/Ann_Conf/2003annual_11.asp
Definitions
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Medical Care (Health Care)
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Lifestyle
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a right is the legal or moral entitlement to do or refrain from doing something or to obtain
or refrain from obtaining an action, thing or recognition in civil society.
Duty
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Choice consists of that mental process of thinking involved with the process of judging the
merits of multiple options and selecting one for action. In this case one of inferior or one
leading to bad consequences.
Rights
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In sociology, a lifestyle is the way a person (or a group) lives. This includes patterns of
social relations, consumption, entertainment, and dress. A lifestyle typically also reflects an
individual's attitudes, values or worldview. Having a specific "lifestyle" can be described as
patterns of behavior based on alternatives given and how easy it is to make this choice over
others given
Poor Choice
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Health care or healthcare is the prevention, treatment, and management of illness and
the preservation of mental and physical well-being through the services offered by the
medical, nursing, and allied health professions.
applied to any action (or course of action) which is regarded as morally incumbent , applied
to any action (or course of action) which is regarded as morally incumbent
Privileges
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is an honor, or permissive activity granted by another person or a government. A privilege is
not a right and in some cases can be revoked
Definitions
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Managed Care
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Plan to control employer's health care cost through the introduction of
practice guidelines or protocols for health care providers, and to
improve the methods used by employers and employees to select
health care providers. The goal of the plan is to create a financial
accounting system in order to manage the impact of medical treatment
on the patient's clinical response and quality of life. Once such a system
is created, the employer and the employee will be better able to judge
which health provider is more effective and efficient. (Answers.com)
Finally, managed care is generally more restrictive on the types of "big
ticket items" it will pay for. Many exclude transplants all together. Most
have annual caps on the amount of prescription drugs they will pay for.
The patient must make up the difference. To offer a real incentive for
cost containment, many HMO primary care physicians are given a
"budget" that varies according to how many patients they oversee. If
they are under their "budget," then they receive all or some of the
difference. Thus, the physician has a financial interest in holding down
the number of tests and expensive procedures s/he allows you to have.
(IJ of Politics and Ethics)
Viewpoints and Perspective
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Legal (US)
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Medical
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The “Hippocratic Oath”
The physician’s ethical duty is to first do no harm to the patient, the practice or
society.
Ethical
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Current laws are vague in that the current legality of withholding healthcare and
level of care falls more in the “errors/omissions” and malpractice with avoidance
of legal obligation to unlimited care.
Right Versus Privilege
Constitutionally healthcare is not a right or obligation of the government.
In the case of justice, we are required to follow due process in order to
determine just limits on health care that will be generally accepted.
Traditional
Social
Economic
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health care is over 15% of our economy
Chronic diseases lead to extreme levels of costs on a individual basis
who is responsible for these costs
Viewpoints and Perspective
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A traditional view is that improvements in health result from advancements in
medical science. The medical model of health focuses on the eradication of illness
through diagnosis and effective treatment.
In contrast, the social model of health places emphasis on changes that can be
made in society and in people's own lifestyles to make the population healthier. It
defines illness from the point of view of the individual's functioning within their
society rather than by monitoring for changes in biological or physiological signs.
One question is whether every person has a fundamental right to have health care
provided to them by their government. Those who feel that health care is a right
believe that societies which are able to provide health care have a duty to do so
equally for all of their citizens. The United Nations' Universal Declaration of
Human Rights enumerates medical care as a right of all people.
The opposing school of thought is that health care can become an entitlement if
government specify it as a right of citizenship, but that it is not a fundamental
right of all people. Furthermore, that it violates fundamental individual rights because
it is a non-essential wealth redistribution.
Source: Wikipedia
Traditional “Poor” Lifestyles
 Personal
Self Management
Diet and Eating Habits
 Lack of Exercise
 Genetics
 Smoking
 Alcohol Abuse
 Drug Abuse
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Potential “Poor Lifestyles”
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Voluntary Occupational “Lifestyles”
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Soldier
Fireman
Policeman
Race Care Driver
All voluntary
 High Risk for Physical Trauma
 High Risk for Mental and Substance Abuse Issues
 Most injuries require substantial costs
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Effects
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“Poor Lifestyle” Effects
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Medical
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Diabetes
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Obesity
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Blood Sugar
Leads to Neuropathy, transplant
Eating Habits
Leads to heart disease and numerous health issues
Cancer
Heart Condition
Addiction
Traumatic Physical Injuries
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High costs with long term rehabilitation
Analysis
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Difficulty lies in the establishment of support for several
areas to include:
Is healthcare a “right or privilege”
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Right involves more responsibility by society and unlimited
access
Privilege involves more responsibility on the patient and possible
restrictions
Poor “Life Styles” create slippery slope for cause and
effect as well as who defines poor “life style”
As medical science evolves the level of diagnosis and
treatment will increase regardless of costs
Costs are real
Ethical Viewpoints
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Obviously one important part of the health care debate
is whether or not a citizen of a country has a right to
health care. If he or she does, then it is the
government's correlative duty to provide this good to the
individual. (4) Thus, if all citizens have a right to health
care, then the government has the correlative duty to
provide it. Therefore, it is an important question
whether or not individuals have a right to health care.
To this end let us examine two theories for the basis of
human rights: (a) Deontologically based rights theory;
(b) Community based rights theory.
A universal right to healthcare. Michael Boylan. International Journal of Politics and Ethics 1.3 (Fall 2001): p197(16).
Moral Viewpoints
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Deontologically Based Rights Theory (Does not depend
exclusively on the consequences of an action to
determine its morality)
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There are a number of versions of deontologically based rights
theory. Many follow from a natural rights tradition. What
concerns us here is a form of the theory that states that there is
some characteristic that all people possess that justifies their
claim to that good as a right. This good is thus claimed solely on
the basis of the claimant's status as a human being (or in some
cases an "adult" human being).
There are several persuasive writers in the natural rights
tradition that, at least, began with John Locke (if not earlier).
The principle problem with this tradition is being able to ground
a theory of rights upon some intersubjective principles. Following
Kant, Alan Gewirth, Alan Donagan and others have tried to
ground a deontological theory based upon the grounds of
human action as per the following argument.
A universal right to healthcare. Michael Boylan. International Journal of Politics and Ethics 1.3 (Fall 2001): p197(16).
Moral Viewpoints
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Clearly, when our bodies are assailed by microbes (disease) or accident, we
are subject to unwarranted bodily harm. Since the protection from such is a
basic good of agency, there is a strong rights claim for the same against all
members of the society subject to the "ought implies can" caveat.
In most cases, behavioral life-styles are either entered into consciously or
via an opaque context. In the case of conscious choices, it would be my
contention that most who choose a deleterious behavior do so out of
ignorance. For example, many in the United States engage in exercise. It is
presented as a healthy lifestyle. …that sports and exercise have combined
to lead to a substantial increase in his practice over the years. Most of
these patients thought they were engaging in something healthy, but it
turned out to be otherwise. By intention these individuals believed that they
were engaging in healthy behavior. There was good scientific evidence to
support this belief. However, in fact, they were planting the seeds of their
own injury. They were ignorant of the actual state of affairs. This is a classic
case of ignorance mitigating culpability.
A universal right to healthcare. Michael Boylan. International Journal of Politics and Ethics 1.3 (Fall
2001): p197(16).
Moral Viewpoints
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The second category concerns opaque contexts. (10) In this case,
the agent does not understand that what she is doing is actually
hurting her. This is because she does not properly make intersubstitutable connections. For example if Jane drinks whiskey, she
knows (a) that whiskey gives her pleasure and (b) that whiskey will
kill her liver. However, when Jane considers drinking she does not
say to herself, "I will now drink whiskey in order to kill my liver."
This is because the context is opaque. lane does not make the
requisite substitution, and thus only sees the proposition, "I will now
drink whiskey in order to receive pleasure." Since an opaque context
is another instance of ignorance, it is my contention that it, also, is
not fully culpable. Because of this, medical personnel should feel
secure in fulfilling their professional obligation of beneficence
without regard to the behavior of their patient.
A universal right to healthcare. Michael Boylan. International Journal of Politics and Ethics 1.3 (Fall 2001): p197(16).
Moral Viewpoints
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Support for Right
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The Argument for the Moral Status of Basic Goods
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Basic Goods
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Everyone has at least a moral right to the Basic Goods of Agency and others in the
society have a duty to provide those goods to all
Level One: Most Deeply Embedded (7) (that which is absolutely necessary for
human action): Food, clothing, shelter, protection from unwarranted bodily harm
Level Two: Deeply Embedded (that which is necessary for effective basic action
within any given society):
Thus, from the point of view of the above deontological theory, all people
have a claims-right to level-one basic goods of agency. This is not an
endorsement of medical procedures that concern secondary goods (such as
cosmetic surgery). First, we have to address the claims of level-one basic
goods.
A universal right to healthcare. Michael Boylan. International Journal of Politics and Ethics 1.3 (Fall 2001): p197(16).
Moral Viewpoints
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Community Based Rights Theory
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Community rights theories may have their origin in Hegel and
have been recently advanced by Michael Sandel. (12)
Justice for the Singer-style communitarian must show that it is in
the community's interest that a universal right to health care be
established. This could be done in a homogeneous community
via ethical intuitionism. Everyone simply immediately grasps the
justification for a right to health care. More popular for
communitarians is an appeal to virtue ethics.
In this argument one might appeal to the virtue of benevolence
(for example) and the shared commitment to the consequences
that benevolence would entail for community health care.
A universal right to healthcare. Michael Boylan. International Journal of Politics and Ethics 1.3 (Fall 2001): p197(16).
Moral Viewpoints
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This idea of correlative rights is derived from Wesley N. Hohfeld,
Fundamental Legal Conceptions (New Haven Conn.: Yale University
Press, 1919).
In that work Hohfeld describes a "claims right." A claim is a right
with a specific correlative duty of the form "x has a right to y
against z in virtue of p."
In this way, rights and duties are correlative. A right of one agent is
identified as the duty of some other agent. A right is a duty seen
from another standpoint.
A universal right to healthcare. Michael Boylan. International Journal of Politics and Ethics 1.3 (Fall 2001): p197(16).
Moral Viewpoints
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Objectivism
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Based on pure capitalism.
Does not consider healthcare to be a right.
Way beyond lifestyle choices being a factor.
"[G]overnment intervention in medicine is immoral in principle and . . . disastrous in
practice. No man . . . has a right to medical care; if he cannot pay for what he needs, then
he must depend on voluntary charity. Government financing of medical expenses . . . even if
it is for only a fraction of the population, necessarily means eventual enslavement of the
doctors and, as a result, a profound deterioration in the quality of medical care for everyone,
including the aged and the poor." -Leonard Peikoff, "Medicine: The Death of a Profession,"
Voice of Reason
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“Under the system of socialized medicine in Canada and Europe, people die because waiting
lists to see doctors are too long to permit them to receive cardiac care in time to save their
lives. In Canada, for example, a patient typically must wait 24 days for an appointment with
a cardiologist--and 15 additional days for the type of emergency bypass surgery that saved
Bill Clinton's life.” -Andrew Bernstein
The moral belief in the right to health care beyond what an individual can afford--health care
at other people's expense--leads inevitably to demand for unnecessary or superficial care
that clogs doctors' offices, overfills hospitals and tasks the health care system beyond its
capacities. The predictable result is the endless waiting lists of socialized medicine.
Comments
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This may be a realistic view of a true poor socialized healthcare system.
Objectivism does not offer a pragmatic solution for our country.
www.aynrand.org
Moral Viewpoints
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Objectivism
"Universal" Health Care Is Immoral
Wednesday, September 13, 2006
Irvine, CA--"Governor Schwarzenegger should be commended for his commitment
to veto the California Health Reliability Act, which seeks to eliminate private medical
insurance and establish a state-run health insurance system in California," said
Yaron Brook, executive director of the Ayn Rand Institute. "But the basic issue is
not, as the governor indicated, that the system would be too expensive. 'Universal'
health care is immoral.
"Health care is not a right. The fact that someone cannot afford the latest medical
test or treatment does not entitle him to force others to pay for it--just as he is not
entitled to a free gym membership on the grounds it would improve his health.
"There is a crisis in health care, but its cause is government interference in the
health care system. The solution is to leave doctors, patients and insurance
companies free to deal with each other on whatever terms they choose--not to
socialize American medicine."
Comments
This does bring up the question of other services we might consider ourselves
entitled to if we consider healthcare as a right.
This raises the issue of how safe our country would be if the government played no
role at all in healthcare.
www.aynrand.org
Obstacles to Moral Action
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"the major issues about right to health
and health care turn on the justifiability of
social expenditures rather than on some
notion of natural, inalienable, or
preexisting rights."
Obstacles to Moral Action
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Ethics can't not play a role, because ethics concerns
whatever is the most important in the way that human
beings treat each other. And so since health is a very
important part of human life, we can't not have ethics in
health care. I guess the other ingredient, is that our
resources for it are limited. And it's not just that the
resources are limited, it's that the obligations of citizens
to help one another are not infinite. We saw in the
collapse of the Soviet Union and the East Bloc that the
idea of a society based on coerced altruism doesn't last.
We certainly have got to have some altruism in
this society, and we have obligations to help our
fellow citizens, but they aren't unlimited. There's
a certain point at which I get to keep a certain
amount of what I have earned and worked for.
Obstacles to Moral Action
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The second thing I think we need to do is to
learn that we have to say no. We have got to be
willing to say no to identified individuals and
make it stick. We have to say no in very careful
ways and have very good reasons for saying no,
but if we're going to draw limits, we have to
actually enforce them. And that means enforcing
them when it affects a real person who's right
here in front of us and who would benefit if we
made an exception.
E. Haavi Morreim, PhD, Professor, Dept. of Human Values and Ethics College of Medicine University of Tennessee
Obstacles to Moral Action
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"All other things being equal." That has to be the most ironic statement ever. It never
occurs in real life.
Who should get treatment first: the smoker or the non-smoker? Oops, I forgot to tell
you, the smoker is 25, the non-smoker is 60. Oh, did I mention that the smoker is a
factory worker and the non-smoker is a Nobelist? One more thing: the smoker is a
widely-loved father of 7, the non-smoker is an neo-Nazi whose only daughter wishes
him dead.
Since "all other things" are never equal, one is forced to assign points to various
traits. How does one assign relative weights? One person might not take care of
himself properly because he spends all his time taking care of others. Another might
be a poster-boy for health and fitness regimens, because he is a self-absorbed
narcissist. Do we really want to reward the latter?
I would guess that few people are so far to one end of the spectrum that the choice
is a no-brainer. The vast majority will be somewhere in the middle, with good health
habits and bad, good personal qualities and bad, good social qualities and bad.
Judging fairly among the vast majority would require omniscience, and discriminating
against the very few "obvious losers" would have little effect.
Conclusion
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Based on the ethical considerations we
believe that “Healthcare”, constituting
treatment, is a “right” of all individuals.
“Lifestyle” which is very subjective and not
well defined cannot be considered capable
of preventing the duty and obligation of
healthcare provider to the patient.
Healthcare cannot be ethically withheld
from patients based on “Poor Lifestyle”.
Probable Reality
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The increased costs of healthcare will
through the very nature of supply and
demand will limit the available resources
capable of providing healthcare. General
triage methods will reduce the level of
care given to patients that have created a
chronic condition from their “Poor
Lifestyle” whether factual or perceived.