Monday 22 May 2017

Healthcare ... A Universal Moral Right

A Barber-surgeon practising blood-letting
Posted by Keith Tidman

Is health care a universal moral right — an irrefutably fundamental ‘good’ within society — that all nations ought to provide as faithfully and practically as they can? Is it a right in that all human beings, worldwide, are entitled to share in as a matter of justice, fairness, dignity, and goodness?

To be clear, no one can claim a right to health as such. As a practical matter, it is an unachievable goal — but there is a perceived right to healthcare. Where health and healthcare intersect — that is, where both are foundational to society — is in the realisation that people have a need for both. Among the distinctions, ‘health’ is a result of sundry determinants, access to adequate healthcare being just one. Other determinants comprise behaviours (such as smoking, drug use, and alcohol abuse), access to nutritious and sufficient food and potable water, absence or prevalence of violence or oppression, and rates of criminal activity, among others. And to be sure, people will continue to suffer from health disorders, despite all the best of intentions by science and medicine. ‘Healthcare’, on the other hand, is something society can and does make choices about, largely as a matter of policymaking and access to resources.

The United Nations, in Article 25 of its ‘Universal Declaration of Human Rights’, provides a framework for theories of healthcare’s essential nature:
“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including . . . medical care and necessary social services, and the right to security in the event of . . . sickness . . . in circumstances beyond his [or her] control.”
The challenge is whether and how nations live up to that well-intentioned declaration, in the spirit of protecting the vulnerable.

At a fundamental level, healthcare ethics comprises values — judgments as to what’s right and wrong, including obligations toward the welfare of other human beings. Rights and obligations are routinely woven into the deliberations of policymakers around the world. In practice, a key challenge in ensuring just practices — and figuring out how to divvy up finite (sometimes sorely constrained) material resources and economic benefits — is how society weighs the relative value of competing demands. Those jostling demands are many and familiar: education, industrial advancement, economic growth, agricultural development, security, equality of prosperity, housing, civil peace, environmental conditions — and all the rest of the demands on resources that societies grapple with in order to prioritise spending.

These competing needs are where similar constraints and inequalities of access persist across socioeconomic demographics and groups within and across nations. Some of these needs, besides being important in their own right, also determine — even if sometimes only obliquely — to health and healthcare. Their interconnectedness and interdependence are folded into what one might label ‘entitlements’, aimed at the wellbeing of individuals and whole populations alike. They are eminently relatable, as well as part and parcel of the overarching issue of social fairness and justice.

The current vexed debate over healthcare provision within the United States among policymakers, academics, pundits, the news media, other stakeholders (such as business executives), and the public at large is just one example of how those competing needs collide. It is also evidence of how the nuts and bolts of healthcare policy rapidly become entangled in the frenzy of opposing dogmas.

On the level of ideology, the healthcare debate is a well-trodden one: how much of the solution to the availability and funding of healthcare services should rest with the public sector, including government programming, mandating, regulation, and spending; and how much (with a nod to the laissez-faire philosophy of Adam Smith in support of free markets) should rest with the private sector, incluidng businesses such as insurance companies, hospitals, and doctors? Yet often missing in all this urgency and the decisions about how to ration healthcare is that the money being spent has not resulted in best health outcomes, based on comparison of certain health metrics with select other countries.

Sparring over public-sector versus private-sector solutions to social issues — as well as over states’ rights versus federalism among the constitutionally enumerated powers — has marked American politics for generations. Healthcare has been no exception. And even in a wealthy nation like the United States, challenges in cobbling together healthcare policy have drilled down into a series of consequential factors. They include whether to exclude specified ailments from coverage, whether preexisting conditions get carved out of (affordable) insured coverage, whether to impose annual or lifetime limits on protections, how much of the nation's gross domestic product to consign to healthcare, and how many tens of millions of people might remain without healthcare or be ominously underinsured, among more — precariously resting on arbitrary decisions. True reform might require starting with a blank slate, then cherry-picking from among other countries’ models of healthcare policy, based on their lessons learned as to what did and did not work over many years. Ideas as to America’s national healthcare are still on the anvil, being hammered by Congress and others into final policy.

Amid all this policy ‘sausage making’, there’s the political sleight-of-hand rhetoric that misdirects by acts of either commission or omission within debates. Yet, do the uninsured still have a moral right to affordable healthcare? Do the underinsured still have a moral right to healthcare? Do people with preexisting conditions still have a moral right to healthcare? Do people who are older, but who do not yet qualify for age-related Medicare protections, have a moral right to healthcare? Absolutely, on all counts. The moral right to healthcare — within society’s financial means — is universal, irreducible, non-dilutable; that is, no authority may discount or deny the moral right of people to at least basic healthcare provision. Within that philosophical context of morally rightful access to healthcare, the bucket of healthcare services provided will understandably vary wildly, from one country to another, pragmatically contingent on how wealthy or poor a country is.

Of course, the needs, perceptions, priorities — and solutions — surrounding the matter of healthcare differ quite dramatically among countries. And to be clear, there’s no imperative that the provision of effective, efficient, fair healthcare services hinge on liberally democratic, Enlightenment-inspired forms of government. Apart from these or other styles of governance, there’s more fundamentally no alternative to local sovereignty in shaping policy. Consider another example of healthcare policy: the distinctly different countries of sub-Saharan Africa pose an interesting case. The value of available and robust healthcare systems is as readily recognized in this part of the world as elsewhere. However, there has been a broadly articulated belief that the healthcare provided is of poor quality. Also, healthcare is considered less important among competing national priorities — such as jobs, agriculture, poverty, corruption, and conflict, among others. Yet, surely the right to healthcare is no less essential to these many populations.

Everything is finite, of course, and healthcare resources are no exception. The provision of healthcare is subject to zero-sum budgeting: the availability of funds for healthcare must compete with the tug of providing other services — from education to defence, from housing to environmental protections, from commerce to energy, from agriculture to transportation. This reality complicates the role of government in its trying to be socially fair and responsive. Yet, it remains incumbent on governments to forge the best healthcare system that circumstances allow. Accordingly, limited resources compel nations to take a fair, rational, nondiscriminatory approach to prioritising who gets what by way of healthcare services, which medical disorders to target at the time of allocation, and how society should reasonably be expected to shoulder the burden of service delivery and costs.

As long ago as the 17th century, René Descartes declared that:
‘... the conservation of health . . . is without doubt the primary good and the foundation of all other goods of this life’. 
However, how much societies spend, and how they decide who gets what share of the available healthcare capital, are questions that continue to divide. The endgame may be summed up, to follow in the spirit of the 18th-century English philosopher Jeremy Bentham, as ‘the greatest happiness for the greatest number [of people]’ for the greatest return on investment of public and private funds dedicated to healthcare. How successfully public and private institutions — in their thinking about resources, distribution, priorities, and obligations — mobilise and agitate for greater commitment comes with implied decisions, moral and practical, about good health to be maintained or restored, lives to be saved, and general wellbeing to be sustained.

Policymakers, in channeling their nations’ integrity and conscience, are pulled in different directions by competing social imperatives. At a macro level, depending on the country, these may include different mixes of crises of the moment, political and social disorder, the shifting sands of declared ideological purity, challenges to social orthodoxy, or attention to simply satiating raw urges for influence (chasing power). In that brew of prioritisation and conflict, policymakers may struggle in coming to grips with what’s ‘too many’ or ‘too few’ resources to devote to healthcare rather than other services and perceived commitments. Decisions must take into account that healthcare is multidimensional: a social, political, economics, humanities, and ethics matter holistically rolled into one. Therefore, some models for providing healthcare turn out to be more responsible, responsive, and accountable than others. These concerns make it all the more vital for governments, institutions, philanthropic organizations, and businesses to collaborate in policymaking, public outreach, program implementation, gauging of outcomes, and decisions about change going forward.

A line is thus often drawn between healthcare needs and other national needs — with the tensions of altruism and self-interest opposed. The distinctions between decisions and actions deemed altruistic and those deemed self-interested are blurred since they must hinge on motives, which are not always transparent. In some cases, actions taken to provide healthcare nationally serve both purposes — for example, what might improve healthcare, and in turn health, on one front (continent, nation, local community) may well keep certain health disorders from another front.

The ground-level aspiration is to maintain people’s health, treat the ill, and crucially, not financially burden families, because what’s not affordable to families in effect doesn’t really exist. That nobly said, there will always be tiered access to healthcare — steered by the emptiness or fullness of coffers, political clout, effectiveness of advocacy, sense of urgency, disease burden, and beneficiaries. Tiered access prompts questions about justice, standards, and equity in healthcare’s administration — as well as about government discretion and compassion. Matters of fairness and equity are more abstract, speculative metrics than are actual healthcare outcomes with respect to a population’s wellbeing, yet the two are inseperable.

Some three centuries after Descartes’ proclamation in favour of health as ‘the primary good’, the United Nations issued to the world the ‘International Covenant on Economic, Social, and Cultural Rights’ and thereby placing its imprimatur on ‘the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’. The world has made headway, where many nations have instituted intricate, encompassing healthcare systems for their own populations, while also collaborating with the governments and local communities of financially stressed nations to undergird treatments through financial aid, program design and implementation, resource distribution, teaching of indigenous populations (and local service providers), setting up of healthcare facilities, provision of preventions and cures, follow-up as to program efficacy, and accountability of responsible parties.

In short, the overarching aim is to convert ethical axioms into practical, implementable social policies and programs.


docmartincohen said...

Thank you, Keith, for this thoughtful essay which seems to have stunned your readers into silence! I think that may be because the piece is in the style of survey of issues, and evidently it is a fair account.

My own thoughts on the broad issue relate to the UK where there is currently a debate about who should pay for looking after old people. Getting old, after all, is something which is not exactly a disease, and certainly not something that can be cured. Yet it requires huge commitments of resources to look after our elderly populations. Traditionally, a large part of the responsiblity has been borne by relatives, that is to say, 'privately', but modern society sees old people increasingly as the responsiblity of the state.

And so, in the UK just this past month, the conservative government attemtped to push the 'burden' back on to the relatives, by saying that elderly people who receive social care at home, will have the bill for that presented to them "after the relative has died" (!) .. This would be in the form of a charge being made by the state against the elderly person's property - property that otherwise would have been inherited by the relatives.

It's a tricky mixture of ethics and politics!

Keith said...

Your discussion, Martin, about aging and how society responds to it is an important one. Your discussion points to some future eventualities in the arena of innovative medical science to slow down the aging process and significantly prolong life. With time and research, it will eventually be possible, for example, to slow down the shortening of telomeres that occurs as cells divide over the course of our lives, a process central to cellular aging in our bodies (biologic, not chronologic, age). And, for example, nanobots (such as injecting molecules to self-assemble into nanostructures) will be used in regenerative medicine to repair and restore tissues and organs, again significantly slowing degeneration and aging. (Maybe aging is a ‘disease’, after all.)

Appreciably increasing people’s life span — say, to 140 — will come, however, with bioethical issues, such as those related to choice, informed consent, safety, and equitable access. It’ll come with other philosophical issues, such as those related to quality of life, vision of the future, free will, understanding of consequences, expectations, and one’s perceived purpose and meaning in those extra years. As well as all sorts of potential social, political, and economic issues, among them: population growth and management; demand on material resources; energy needs (and new energy technologies); environmental protections; tenure in the workplace, and space for young people entering the workforce; ongoing training to avoid knowledge obsolescence; productivity and potential for economic growth; retirement, including accumulation of assets to sustain it; government roles, responsibilities, and policymaking in problem solving; institutional adaptions across the board; decreases in violent crime; coping with disruptive technologies — and all the rest.

As you say, ‘It’s a tricky mixture of ethics and politics!’

Tessa den Uyl said...

This 140 sounds a bit shocking to me! Healthcare is one, increasing the lifespan another. One reflects care, the other a problem with death?

Keith said...

Perhaps, Tessa, the issue is not so much ‘a problem with death,’ but rather the flip side, ‘an excitement with life’. It depends, I suppose, on the mind-set of the individual. Of course, the 140 years was just an example, though an attainable one; the actual gains in lifespan, resulting from advances in medical science in the coming decades, may eventually exceed that number. That’s not so outrageous, if looked at through the lens of history: In ancient Rome, life expectancy at birth was around 25 to 30 (especially taking into account infant mortality); between 1900 and today, average global life expectancy (with regional disparities, of course) more than doubled, to around 70. Seen in that light, the 140-year target might, arguably, prove no more unnerving or unnatural than those sizable historical gains in lifespan. People have long since pocketed those gains. I would propose that, whether because of ‘a problem with death’ or ‘an excitement with life’, people have instinctively sought to live longer, and will continue to do so. I’ll go out on a limb, but I doubt many people today would favour reverting to the life expectancy of ancient Rome; I also doubt that, once 140 is the average, many people will favour reverting to the life expectancy of 2017.

docmartincohen said...

I have heard experts on such things saying that life expectancy has increased far less than the medical establishment claims, that in ancient China, for example, a well-off person might well live to be 80. Our figures on life expectancy are determined by things like disease, infant survival, accidents...

What seems striking to me is the detioration in our mental processes. This is the issue when talking about the ballooning ocosts of social care. These are people who re still functioning perfectly well in the simple 'physical' sense, but whose ability to take decisions, to remember everyday things has diminished.

There are sad cases of people who are alive, as shells, and in the past might not have been, but as Tessa's query also suggests, for whom are they living for now?

Keith said...

Yes, Martin, I totally agree: no doubt some fortunate people in ancient China lived to see 80 — as some undoubtedly did in ancient Egypt, ancient Greece, ancient Rome, and the Middle Ages. The unfortunates were the rest of the toiling souls, whose lives evoked Thomas Hobbes’s memorable description as ‘solitary, poor, nasty, brutish, and short’. As you rightly point out, one of the serious downsides to our living longer in droves is the epidemic of age-related dementia like Alzheimer’s disease. (Witness the Baby Boomers.) The gradual peeling away of cognitive skills — to get ever closer to the ‘shell’ you refer to — is hard for families to witness. And certainly, as you suggest, raises philosophical questions about quality of life. But as thorny as these health problems are, I have faith that medical science will figure out how to tackle age-related illnesses like neurodegeneration — both preventatively and curatively — and to do so through parallel research, hand-in-hand with increases in lifespan. I suspect there’s a certain amount of natural leapfrogging that goes on. I’m not a historian of medicine, so I’m on shaky ground, but I don’t think this is vastly different from the history of cancer and cardiovascular disease, including society’s need to mobilise, also associated with aging.

Thomas O. Scarborough said...

I would think there are few if any countries without socialised health care. Given that this is the case, some core questions would be (thinking both locally and globally): who is responsible for such health care, how shall there be accountability for its failures, what is bottom line health care, what are doctors' broader moral responsibilities? and so on. I was at a bit of a loss to know what the post is about, as it is indeed 'in the style of survey'. A little bit of this, and a little bit of that, and stir.

docmartincohen said...

It's true that the piece is not structured in the form of a conventional philosophical argument: ie. premises leading to a conclusion, but Keith offers a survey in the social scientific sense of health to illustrate how ethics and policy are interweaved in these matters.

docmartincohen said...

Yes, we might say life is all about 'quality' not 'quantity', mightn't we! But today's societies are based on 'more is better'...

Keith said...

Actually, Thomas, the United States is a major exception to your claim about the purported ubiquity of socialised healthcare. The vast majority of Americans’ coverage for healthcare expenses comes from private insurance companies, obtained mostly through their employers, with others buying insurance in the open marketplace on their own. I’ve seen numbers like 70 percent of the American population getting private health insurance through a combination of these two (private-sector) means. The debate over healthcare insurance programs during the last administration and the current one won’t materially change that formula, with the important exception of trying to get even more of the currently uninsured and underinsured to have access to adequate insurance — but again, with private insurance companies at the center of that play. So, no, the United States’ healthcare system isn’t ‘socialised’ — nor is it likely to become so in the foreseeable future.

Thomas O. Scarborough said...

I am aware of the example of the USA. My focus was on core questions.

Keith said...

I agree, Thomas, that the core questions you raise are indeed important ones among many; and, I’d like to think, the core questions my post raises are important ones among many. This matter of identifying ‘core questions’ graphically underscores an obvious point: that a comprehensive discussion of how issues of healthcare and issues of ethics intersect is large, multifaceted, difficult, and challenging — but a conversation worth having, in various venues.

In case you’re interested, here’s a link to a 'Washington Post' article from a few days ago, describing a heart-wrenching situation where healthcare has thus far failed, the consequences have been dire, and where, I’d argue, knotty questions about ethics — still more ‘core questions’ — arise. A situation that could disturbingly be in any number of other locations around the world.

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