Phil335Unit 3 - Summary Biomedical Ethics PDF

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Phil335Unit 3 - Summary Biomedical Ethics...

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Unit 3 1. What are the basic characteristics of the libertarian health care system, and how does this system differ from one premised on the modified-egalitarian model? The libertarian model of health care is linked to freedom, and an example of a country that has a version of this is the US. In this system health is a service and the marketplace determines its availability and distribution. There is freedom to produce, offer, and purchase health care resources, goods, and services. Under this system not even essential health care is available to all people equally. Health is a commodity and those that can afford health care from their own finances are in a better position to receive care. In US you are only guaranteed as much health insurance as you are able to buy. There is minimal coverage for those that cannot afford it, leaving many people not covered. The freedom is that, those who are healthy do not have to pay for people who are sick, the problem is that we cannot predict what accidents will happen to us or what financial or health changes we will encounter. On a larger scale this model supports a “victim blaming” view of health and undermines the social, political, environment, educational and more factors that influence health status of a population. The biggest difference from the modified-egalitarian model is the lack of equality in libertarian care models. The modified egalitarian model is universally available and publically funded by taxes. It gives citizens the right to basic health care. In my opinion, this helps to acknowledge the many social determinants of health outside of the individuals control and offers a sense of security for the unknown. It demonstrates that society values caring for each other. Other benefits of the modified-egalitarian model are: limited bureaucracy and physicians have more professional autonomy (by not being influence by insurance companies and organizations depicting what treatment can be done). 2. What do you think are the greatest advantages of the modified-egalitarian model as compared to the libertarian model? Do they outweigh its disadvantages?

The greatest advantage of the modified-egalitarian model is equality. Knowing the social determinants of health it is beneficial to have health care for all patrons. Personally, as a Canadian I take comfort in knowing that my basic health care is covered. I am proud that my country values caring for one another. However, the right to have access to basic health care is a characteristic that many Canadians are accused of taking for granted. Hence the Canadian model has been criticized for having poor measures of efficiency and poor incentives for cost containment. For example, a Canadian may go to their doctor for a common cold, where are someone in a libertarian system may refrain so that they do not endure the cost personally. On the other side, someone living in a libertarian health care system may delay going to the doctor until it is approved by insurance company and miss the chance of having an early diagnosis in the event of a more serious health condition.

This system does not come without disadvantages. Disadvantages that have been evident in the media are the growing concern around how to financially support the obesity epidemic, the aging population, and cost of advancing technology. The Canadian system has been critiqued for having long wait times as well. However, by having a heath care system that does not blame the individual but accounts for social determinants other government ministries can be called upon to help support the health of Canadians. 3.. Are there changes to the modified-egalitarian model that would improve health care in Canada? Can your suggested changes be defended on ethical or economic grounds? The modified egalitarian model is based on the Canadian value to act as a society that treats each other with equality, thus we have a single tiered system. However the cost of Canadian health care is ever rising, as is our national debt. This concern amoung others, have lead to debate over health reform in Canada. One of the most discussed options would be to move to a two-tier system, the first tier being public and the second tier being private. The first tier would provide services that are considered “medically” necessary. The second tier would be for treatments seen as “medically unnecessary” allow for people that can afford to pay privately to access care outside of the public system. This would simply put those that cannot afford “unnecessary” treatments at a disadvantage. It would be very difficult to distinguish between what is necessary and unnecessary in the context of people’s lives. For example, what if a person needed surgery that was medically “unnecessary” to perform their duties at work, not being able to pay for the surgery would also make them unfit for work. Stingl suggests that we could reinterpret “basic” to refer only to services that we can publically fund for all people equally, but this means that some people will be saved in life and death situations and some won’t be, which obviously does not seem fair. This becomes very complicated when some people can afford this service. It does not seem ethical or reasonable to introduce inequalities into our health care system by creating a two-tiered system, which would put those with greater financial circumstances above those in lower socioeconomic status and have an unknown effect on the publicly funded side. To help think about this I will provide an example, you need knee surgery but know that you are on a wait list and it could be months before the surgery takes place. You are an avid soccer player and thus your knee is essential to who you are and what you do. A two-tiered system would allow for you to pay privately to have this surgery quicker. You are able to afford the surgery and decide it is worth the investment. Plus, now the person waiting for knee surgery behind you that cannot afford to pay privately will also have their surgery faster. The idea that is that this two tier system would give people who can pay the option of having the surgery sooner, and freeing the weight times for the people who cannot afford to pay, it sounds like a win-win situation. However, under critical analysis there are many reasons to disagree with this system. Personally, I think this would create disparities. For example, some people think that this will help reduce wait time for people of a lower social economic status because people who can afford to pay would have the surgery privately. However, clinicians may have more incentives to work in these

“private pay” sanctions to make more money, and the motivation would be less in the public sectors, making the availability scarce. Canadians have been accused of taking their free health care for granted. Perhaps showing the cost of services and mailing bills or having an online profile to show the cost could help people appreciate the system. I believe this would help to increase public knowledge of health care spending. On the downside there would be an additional cost to tabulating and preparing these documents. 4. In your view, what are the goals of medicine? How best can these goals be met? Include a discussion of health research in your answer. The goal of medicine should be to help keep people functioning in their activities of daily living while achieving a high quality of life for their given circumstance. Medicine should be accessible to all Canadians. When I think about “medicine” I often think of the acute care system. But the goals of health are much wider. In my opinion, a major goal of medicine should be preventative care. For example, there are a multitude of health issues that could be resolved or lessened if Canadians were more physically active. The benefits of physical activity are well known, yet hardly practiced. A more specific example would be the obesity epidemic and sedentary children. By promoting physical activity Canadian children could be healthier and also lesson the burden on the acute care system. One example of how Canada is doing this is by funding research initiatives like ParticipACTION. Health research is a macro-allocation issue. Health policy decisions are based upon research and research funding is based upon health policy. Researchers need to “market” their research in a way that appeals to the federal granting agencies if they hope to receive funding. Granting agencies can influence the field of research by looking for applications in specific areas of health research, as Lippmann describes with the human genome project. The problem is that how you define “health” will change the scope of research, and the research areas that are funded. Vice versa, the research that is being conducted will influence how you define “health”. Lippmann’s article discusses the pitfalls of focusing on researching the human genome largely because it reverts back to a view of health that emphasizes “genetic” factors and will even result in some diseases being reclassified as genetic diseases. Lippmann disagrees with this because it places health in the hands of the individual not society and mitigates the fact that health is determined by a large number of factors beyond the individual’s control. When it comes to medicine we must widen our scope to include larger factors. 5. With respect to the micro-allocation of organ transplants, would you consider yourself a utilitarian, a bare Kantian, a fair Kantian, or something else? Utilitarian

Concerned with maximizing the outcome

Use comparative criteria: life expectancy, prospects for recovery, family role, and more Objection: undermines a respect for the equal value of every humans life Bare Kantian

Treat people equally Use queing (first come first served), drawing lots, or random selection Objection: seems wrong to flip a coin to decide who lives between a murdered and a saint

Fair Kantian

Treat people as equals does not necessarily mean to treat people equally *Treat the equal worth of people by treating them differently when context demands it *like the combined method below

With respect to micro-allocation of organ transplants I would consider myself in favour of the fair Kantian approach, like the model proposed by Annas. Organ transplants come with many complications, and maximizing the medical outcome would be the best way to allocate a scarce resource. Where people fit the same medical screening, I would favour a queuing system so that everyone that wants an organ transplant has a chance at receiving it. However, in situations where someone needs an organ more urgently, I would want the system to have flexibility to move them ahead in the queue. 6. Do you agree that some criteria that could be used to compare transplant candidates are morally irrelevant (or even offensive)? If yes, which ones, and why? If not, why not? We live in a time where freedom and individuality and acceptance are all highly valued, but with this has come a tendency for the public to become irrationally offended at anything that can be deemed “politically incorrect”. Thus, use of the Committee Selection model would inevitably result in public outrage at many of the criteria being used for patient evaluation. However, in a committee composed of human beings, it is impossible to eliminate the personal opinions and biases held by all humans, no matter how accepting and liberal we are. For example, it is morally irrelevant to judge directly based on gender, race, sexual orientation, profession/social class, family and connections, criminal record, religion/culture, lifestyle habits, etc. However,

some of the criteria listed may be interrelated with factors that directly affect health and the probability of a successful transplant. For example, a person of low socioeconomic standing may not be able to afford the care required after transplantation, and someone without a family may not be able to care for themselves. Thus, while I believe it is immoral to use any of the above categories to evaluate a person for transplantation, I do think that they may be involved in determining medically relevant factors that must be considered. If they are to be used, there must always be a medical justification that is the only purpose for using the criterion. 7. Do you agree with Annas that his model for micro-allocation is the best model available in the case of organ transplants? Why or why not? I agree that Annas model is the best of the models presented for organ transplants, it prevents some of the negative allegations against the committee and lottery approaches, although it is not without pitfalls itself. I feel that being frank about the operation should be done prior to the first and second level of selection. I feel that patients have the right to know the details of the operation and this should be the duty of the physician and medical team but the patient should not be made to feel intimidated or coerced out of going through with it or guilty for receiving the organ. I agree with the medical screening of the patient and find this to be a highly likeable feature of Annas model, but he suggests that an ethics committee be included and public report published, in a time sensitive case this would be a pitfall. I also feel that it would be difficult for physicians to predict the likelihood of someone living for 5 years post operation, but I am not a physician. In my opinion, further studies would need to be completed to understand the validity of this measure. I like the feature that allows for flexibility in the first come- first served for more serious cases, but as a person waiting to receive an organ it would be devastating to continue to be informed that someone else jumped ahead of you in line, especially if it had implications for you like being on a dialyses machine. One more consideration that is not discusses is the size of the pool. What I mean by this is, is the pool the size of Canada, a province, a city, a community, etc. People deserve equal chance at accessing a kidney regardless of their geographic location.

Committee Selection Model

Decides using a utilitarian model & compare recipients on a number of indices (which could be morally relevant or irrelevant)

(utilitarian)

*Personally, would not want to be subject to the biases of the committee members 2 Main Problems: 1) Select a committee to avoid giving criteria for selection but either a set of criteria will be developed to

decide (which you would not longer need the committee) OR criteria would not develop meaning the group is corrupt for deciding arbitrarily (randomly) or dishonestly (unfairly). 2) Preference for specific individuals over others— requires devaluing someone life Objection: without a sense of equality and fairness, subject to bias of the committee The Lottery Model

Puts equality above every other value (both a strength and a weakness)

(Kantian)

Uses a lottery method like drawing lots or first come-first served (queuing). Therefore it promotes equality and eliminates bias due to race, colour, creed, socioeconomic status, etc. But also the important medical information like potential survival, quality of life, urgency, etc. Also referalls are more likely to happen to the financially well off (therefore more likely to be higher on the list). Therefore it tries to prioritizes equality but does not succeed Objection: individual with ¼ chance of living 5 yrs with transplant but could only survive for 6 months without getting an organ before someone who could survive longer but die within days or hours if not immediately transplanted

Annas Model -more like Fair Kantian

Two leveled model 1)

Medical Criteria Initial Screening: 

Ensure that everyone in need, regardless of social status, is given a chance (eliminates referrals issue in lottery model)



Probability of a successful transplant & patient survives for at least 5 years (may be hard to determine or predict)



Ethics committee reviews the list of acceptable candidates (how do you keep out social worth/bias?), report available for public scrutiny (what about time sensitive cases—as described above)

2) choose between individual candidates that pass the initial screening by first come first served BUT able to be flexible for case described above 3) Give people a choice if they want the surgery or not (should this be first?) Ban All Organ Transplants

If you can’t save everyone, don’t save anyone

Market Approach

Provide an organ to everyone who could pay- highly criticized Ex. transplant technology is paid for by public, high value on individual rights and low on equality and fairness (libertarian) *Putting a price on human life

Customary Approach

*Situations arise where we do not save peoples lives because it is too expensive to do so...