LAST BIOETHICS MOTHERUFCKING QUIZ

justice principle

'equals should be treated equally'. So, people should be treated the same, unless there is a morally relevant reason for treating them differently.

Engelhardt (1996) defends libertarianism

with respect to health care: the government may coerce to preserve liberty, but a universal right to health care, funded by taxes, would be unjust (yet not private health care and voluntary charity).

But are the bad outcomes of the social lottery unfair - or just misfortunes?

¤ According to Engelhardt, it depends: A. If the actions of others are not malevolent or blameworthy, bad outcomes are not unfair: 'Some deny themselves immediate pleasures in order to accumulate wealth or to leave inheritances; through a complex web of love, affection, and mutual interest, individuals convey resources, one to another, so that those who are favored prosper and those who are ignored languish' (711). B. If the actions (or omissions) of others are malevolent or blameworthy, bad outcomes (e.g. poverty, disease) are unfair - and the government should correct that with police protection, forced restitution and charity.

¤ But how does Engelhardt argue for his view?

First, he notes that the right to health care is a positive right: a claim on services and goods of others or a moral obligation on others to help us when in need. ¤ Positive rights depend on particular accounts of what is good, beneficent or just. Only with such an account in mind can we determine what help someone deserves. ¤ But in secular democracies, there are '...as many accounts of beneficence, justice, and fairness as there are major religions' (709) - and thus no consensus that could morally legitimize positive moral rights, including the right to health care.¤ Second, Engelhardt acknowledges that there is inequality in society - and that inequality motivates interest in justice and beneficence. ¤ But, he points out, not all inequalities are unjust: they don't necessarily generate rights or claims against others. In part, that is because the resources required to help those in need are already (rightfully) owned by others

On Daniels' view, what does the right to health care include?

'...social obligations to design a health-care system that protects opportunity through an appropriate set of health-care services' (699). If these social obligations are not met, we are being morally wronged or treated unjustly. E.g. not getting access to basic services that ensure normal functioning; basic tier doesn't include important categories (e.g. prevention, mental health).

So, according to Engelhardt, there is no moral right to health care:

'The imposition of a single-tier, all-encompassing health care system is morally unjustifiable' (709).

utilitiarianism

(e.g. Mill): a just distribution of benefits and burdens maximizes the net good or utility for society; depending on a society's resources, needs and likely effects of allocation policies, several forms of health care might turn out to be just (e.g. universal health care insurance, qualified right to health care).

libertarianism

(e.g. Nozick): a just distribution of benefits and burdens results from the exercise of liberty and free markets; the government may coerce to preserve liberty, but a universal right to health care, funded by taxes, would be unjust (yet not private health care and voluntary charity).

egalitarianism

(e.g. Rawls): a just distribution of benefits and burdens is an equal distribution; governments may interfere with the free market and redistribute benefits and burdens; several health care schemes could be just in an egalitarian sense (e.g. universal health insurance, health care only for the most needy).

Engelhardt distinguishes unfairness from misfortunes

1. Natural Lottery: on the one hand, natural forces (e.g. genetics, natural disasters) change our fortunes and shape the distribution of natural assets (e.g. talents, skills, health); winning the natural lottery means not needing medical care, while losing it means being in need of medical care. 2. Social Lottery: on the other hand, actions of others change our fortunes and shape the distribution of natural and social assets (e.g. income, wealth, education); those who win the social lottery will accumulate assets, while those who lose it won't.

Harris' Criticism of QALYs:

1. Misrepresenting Preferences: While most patients prefer a healthier, yet shorter life to a longer life of pain or disability, they probably don't prefer their own death to a longer life of pain or disability. But QALYs seem to imply that when 2 (or more) patients are involved - and one of them could have a healthier, yet shorter life at the expense of the others. 2. Absurd Implications: adopting QALYs means valuing life years rather than people's lives. So, maximizing QALYs would mean increasing the world's population - and discouraging birth control, abortion & sex education! That, though, seems absurd. 3. Discrimination: QALYs lead to discrimination (or violates equality): i. Ageism: saving younger people (e.g. neonatal care, pediatrics) is always more likely to produce more QALYs than saving older people. So, QALYs are ageist. E.g. heart transplant for 15 year old vs. 70 year old. ii. Racism & Sexism: QALYs prioritize medical conditions with cheap treatments - which might lead to or perpetuate discrimination on grounds of gender or race. E.g. diabetes in Canadian Aboriginal women [http://tinyurl.com/mn4r6o5]; sickle cell anemia in sub-Saharan Africa [http://tinyurl.com/lt9vdhn]. iii. Ableism: QALYs favor patients who won't be disabled after treatment. For instance, QALYs would recommend saving the life of someone who would be restored to perfect health for 5 years over someone who would live 30+ years, yet as a paraplegic. iv. QALY-ism: QALYs favor patients with higher expected quality of life. But that is discriminatory in itself because 'the life and health of each person matters, and matters as much as that of any other' (743) 4. No Life-Saving/Life-Enhancing Distinction: we distinguish between life-saving and lifeenhancing treatments - and generally prioritize the former over the latter (e.g. dialysis over hip replacement). But QALYs don't respect that distinction

QALYs seem attractive because they respect patient values or preferences:

1. Most patients value both quantity and quality of life; 2. Most patients prefer a shorter healthier life to a longer life of severe discomfort or disability. (Or: most patients prioritize quality over quantity.)

2 Limitations (on Health Care):

1. The way in which health care protects equality of opportunity is mitigated by other factors such as the distribution of wealth, income or education. 2. Health care leaves the normal distribution of skills and talents unmodified; it does not support physical, emotional or cognitive enhancement beyond the normal range.

Daniels (1998: 698-99) offers two reasons in response

1. it would make the administration of the health care system much more difficult; 2. it ignores an important fact about justice: equality must be reconciled with liberty and efficiency (and thus normal functioning as a reasonable limit).

Alternative to QALYs?

A. Defensive Medicine: health care resources are not justifiably as limited as they appear; in fact, they should make up a larger chunk of the national budget: 'Since the citizens in question are in real and present danger of death, the issue of the allocation of resources to life-saving is naturally one of, among other things, national defense' (745). B. Life-Saving as Priority: when disaster strikes, we must prioritize saving lives absolutely; 'Among the sorts of disasters that force us to choose between lives, is not the disaster of overspending a limited health care budget!' (ibid.)

¤ But how can we measure efficiency?

According to some Utilitarians (e.g. Williams 1985), the most efficient use would maximize quality-adjusted life years (or QALYs).

How does Daniels argue for his view?

Big Idea: '...disease and disability restrict the range of opportunities that would otherwise be open to individuals' (698); so, the aim of health care is to keep people functioning as close to normally as possible (which includes physical, emotional and cognitive capacities) - and thus preserve equality of opportunity.

¤ But: how equal must our rights to health care be?

But, he points out, resources for the basic tier are appropriately and reasonably limited, given that health care is not the only important good. So, some beneficial medical services won't be part of it - which could be bought by those who can afford them. There's nothing wrong with that: we allow people to freely use their after-tax income and wealth as they see fit!

But: not all medical needs are equally morally important!

Daniels' response: a medical need is only as morally important as the degree to which it restricts the range of opportunities. So, his view gives us some guidance about how to prioritize resource allocation! ¤ Still, Daniels admits, measuring moral importance or priority by effect on opportunity is crude and incomplete. So, very hard choices remain: e.g. cure few with a significant sickness - or many with a less significant one? ¤ Ultimately, these choices will have to be made by a fair, publicly accountable, decision-making process. But what that process looks like is both controversial and hasn't been examined properly yet in the literature.

Engelhardt's Libertarianism

Libertarianism is the view that a just (or fair) distribution of benefits and burdens results from the exercise of liberty and free markets

How should we ration health care resources?

People's health care needs are boundless, but our health care resources (e.g. organ transplants) are finite. Utilitarians suggest that we objectively measure and maximize the benefits that a treatment is likely to give to a patient (namely in terms of 'quality-adjusted life years'). However, John Harris (1987) argues that this suggestion leads to morally unacceptable implications (e.g. ageism).

(Daniels egalitarianism) is there a moral right to health care?

Some preliminaries: 1. Moral (not: Legal) Right: we are interested not in whether there currently is a legal right to health care - but whether individuals have a moral right to it. 2. Positive (not: Negative) Right: the right to health care would be a positive right, i.e. it would put moral obligations on others to help us (not: not interfere with us by, e.g., not polluting the environment). 3. Welfare Rights: the right to health care is part of welfare rights (e.g. education, training). 4. Context: having a moral right to health care only makes sense within a health care system - and is compatible with not being honored due to resource scarcity.

But: what counts as effectively promoting normal functioning?

To start with, Daniels argues, we should rely on treatments that have some proven safety and effectiveness (even if that is difficult to gauge with respect to novel treatments). ¤ Beyond that, 'what counts as 'reasonably effective' is a matter of judgment and depends on the kind of [medical] condition and the consequences of not correcting it' (699). Consider: last resort vs. scarcity. ¤ Finally, the focus on normal functioning allows Daniels to distinguish between medical treatments we need (and thus deserve) and treatments we merely want (e.g. cosmetic plastic surgery, life coaching). ¤ Still, hard cases remain: what about non-therapeutic abortion, fertility treatment or growth hormones?

justice

Very roughly, justice refers to people getting what is fair or what is their due.

do we have a moral right to health care?

While Norman Daniels (1998) argues that we can derive a moral right to health care from John Rawls' (1971) 'fair equality of opportunity', Tristram Engelhardt (1996) denies that because suffering from bad fortune need not be unfair.

Harris' Criticism of QALYs

argues that it is morally wrong to use QALYs when deciding which patient group or medical condition deserves medical treatment. (So, he objects to B-, yet not A-, uses of QALYs.)

distributive justice

justice regarding the fair distribution of society's advantages and disadvantages (e.g. income, property, employment, taxes, rights, health care).

Instead, Engelhardt wants us to opt for a multi-tier system

since it '...allows for the expression of individual love and the pursuit of private advantage, though still supporting a general social sympathy for those in need' (715). But, importantly and unlike Daniels, there is no guaranteed access to basic medical care.