Existential Crisis

 Our next class discussion is focused on the 2020 Netflix Documentary David Attenborough: A Life On Our Planet. Since we recently finished the last chapter of Medical Ethics, the last two weeks or so of the semester will be more on environmental ethics, and this documentary is an excellent introduction into that. Many of the issues with environmental ethics and environmental conservation efforts exist because humans are the worst.

Arguably the biggest error in human history is that of the loss of Earth's wild places and its biodiversity. The way that humans currently live is sending biodiversity into a decline due to bad planning and actions. This will eventually lead us to a place where we can't live anymore. Earth's evolutionary history speaks of slow, steady change, with mass extinctions marking each period of life. The most recent period, the Holocene, is the most stable of these periods, and its biodiversity contributed to that stability. Due to its stability and predictability, humans have been able to flourish, which contributed to the discovery/invention of farming, and civilizations followed. For humans, our major evolutionary advantage is our intelligence. Instead of needing to develop a major physical change, we have thought our way around many problems. We've seen though that the available resources on our planet are not limitless, and without major changes, we'll soon see the complete destruction of natural habitats and the extinction of countless more species than have already been lost.

The way we've been living is unsustainable. Overfishing, cutting down rainforests, polluting the air and the oceans; all of these are contributing to the dying state of the natural, "wild" world. Coral bleaching, destruction of the polar ice caps, deforestation, overuse of fertile land, and so many other examples, are evidence of the abuse humans have caused on the planet we call home. We've claimed this planet as our own, and instead of being run by all of the species and enjoying stability due to its biodiversity, human beings have overrun and destroyed much of it. We've made it our planet, run by humankind for humankind.

So, what? Clearly we can't continue on this way, it's unsustainable. And anything that is unsustainable can't be sustained forever, that's the definition of the word. The wild will continue on, so finding a way forward isn't about saving our planet but more about saving ourselves. The natural world will rebuild itself, the same way it has reclaimed Chernobyl after the radioactive accident in the 1980s. The living world will endure, but humans can't presume that we will have the same fate if we don't change something. We need more than just our intelligence, we need wisdom.

We need to find a way to restore the Earth's biodiversity to reestablish its stability and sustainability. The first of these steps is a controversial one, but it's one that is inevitable. As more of the world is turning into developed nations, we will eventually see the slowing/stop of population growth. To reach a human population peak, we'll need to take steps to raise people out of poverty, improve access to healthcare, and enable people (especially girls) to stay in school as long as possible. This will contribute to an earlier, lower peak in population and give people greater opportunity; ideally raising the standard of living throughout the world without raising our impact on the world. 

Another necessary move toward sustainability is living in a naturally-powered world, phasing out fossil fuels and running the world on energy derived from geothermal, solar, wind, and water energies. Investing in these energies and divesting from fossil fuels will lead to quieter, cleaner cities. Renewable energy doesn't run out, by definition of the word, and overall this would drastically reduce the impact of humans on the natural world. 

In addition to this, the living world can't operate without a living and healthy ocean, and increased diversity will help to solve that problem as well. One proposed solution is that of restricting fishing areas and following a model set up by the island of Palau and setting specified "no fish" zones. If the UN's plan to set up a large "no fish" zone in international waters is successful, they will effectively set up the world's biggest wildlife reserve and will move us toward repopulating the ocean and provide more fish than we would ever need to survive. 

That's the situation with the ocean, but a similar one is needed on the land as well. Humans need to radically reduce the area we're using to farm in order to return wilderness, and the best way to do that is to change our diets. Large carnivores are rare in the wild because it takes a massive amount of prey to support them, so humans need to reduce our overall intake of meat. Largely plant-based diets would move us closer to using half the land we currently use and by following more sustainable farming models we could also increase productivity of the land we're using. The technology is available, and producing food in new locations (indoors, in cities, in oceans, etc.) would increase food production and reduce the space used, thereby reversing the "land grab" that humans have been participating in/pursuing since we started farming. 

10,000 years ago humans were hunter/gatherers out of necessity and sustainability, and now it's our only option again to be sustainable. We can solve the problems we've created by taking care of nature and allowing it to then take care of us. We need to establish a life that is in balance with nature, becoming part of nature again, instead of living apart from nature and benefitting from the land without ensuring its future. A sustainable, long-lasting future is possible, but to get there we have to start by listening to scientists and conservationists and doing what we can to guarantee a future where humans are a sustainable part of life on Earth. Otherwise, it will move on without us.

Film citation:

Fothergill, A., Hughes, J., & Scholey, K. (Directors). (2020). David Attenborough: A Life On Our Planet [Motion picture]. Denmark: Altitude Film Entertainment; Netflix; Silverback Films.

The Answer

I'm writing this post before Thanksgiving break, but soon we'll be heading into finals. Speaking of Thanksgiving though, people often associate food, and sometimes overeating, with the holiday season, and dieting and weight loss with New Year's, so this discussion is especially relevant this time of year.

I couldn't possibly talk about food on this blog without including a tribute to Eleanor's love of shrimp, so here's a GIF of Kristen Bell having a moment while eating shrimp.

The final chapter in Medical Ethics is on the ethics of weight management and covers a variety of topics and ethical considerations. 

The take on weight control that was probably the very first is that all of us are responsible for our own weight. Free will and all that. Thanks, Kant. This stance is one that many Americans currently agree with, a 2016 study found that most people think that losing extra weight is always possible through dieting and exercise (Pence 478). It's interesting to note that a 2017 study showed the number of people who gave up on dieting has increased in the last decade, but also that some bioethicists believe that fat-shaming is the correct way to fight the pandemic of obesity. While I can see the makings of logic in this argument, I don't think that social stigma is ever the answer to anything if you want a positive outcome. 

Regardless of age, height, diet, ethnicity, etc., your weight may depend on the genes you inherit and how those genes are expressed. Some researchers believe that roughly half a person's risk for severe obesity is genetic (Pence 479). Various studies back these claims, though many say that these conclusions are speculative at best. 

Metabolism also has a hand in weight, as has been demonstrated by The Biggest Loser and the contestants whose weight and metabolic rates repeatedly had the same result, gaining back the weight that was originally lost. Though there are several reasons why the "results" of the show are a sham, this is a large part of it. Research has shown that even small weight gains and/or losses shift biological homeostasis, so major changes would only have bigger effects. 

This isn't entirely a biological fight though, social factors play a part in this as they do with many other things. Poverty discourages people from access to better resources, including food, exercise, hygiene, and many others. Cheap, processed foods are more widespread, thus leading to "Westernized" diets and poorer health in many countries (Pence 481). 

The biggest question/consideration in this chapter, in my opinion, is whether or not being healthy is the same as being thin. Physician Faith Fitzgerald stated in 1994 that the idea that people can choose healthy lifestyles has, "a very dark side...that leads to a tyranny of health in the United States" (Pence 482). This idea of "wellness" that can be chosen or pursued is dangerous and fits in directly with fat stigma and fat shaming. Language matters. Just because there is a history of dark and prejudiced humor around weight doesn't make it okay to use negative or shaming language around the topic. Physicians get no education in medical school about compassionate ways of dealing with overweight patients, which also contributes to the bias (Pence 485). Research has shown that bias begins early and has been called the last socially acceptable form of prejudice and is as common in society as racial prejudice. Prejudice that is then internalized and leads to a vicious cycle of binge-eating and social withdrawal. This helps nobody. 

One researcher stated that, "the difficulty in keeping weight off reflects biology, not a pathological lack of willpower," and humiliating people in an attempt to motivate them to lose weight is a paradigm of the fallacy of blaming the victim. Victim blaming in this case often leads to self-harm and other destructive behaviors that put them at risk of real danger. Modern societies often have an ideal of thinness, and in a world that was built for "cis, thin, white people" this works, but at the cost of everyone who doesn't fit this definition of "normal" (Pence 485-6). BMI doesn't necessarily describe a person's health, as the location of fat in the human body determines a lot more about a person's health than does the percentage of fat tissue (whether or not the fat is around organs or under the skin). 

Some public policy has been created in an attempt to help with the obesity pandemic, such as soda taxes and policies surrounding bariatric surgeries. Although good intentions come with these, it will be many years before real change is seen.

It is also important to consider the fact that there is not only one cause of weight gain. Some researchers believe that they have discovered about 60 different kinds of obesity, while others have found that 25+ genes contain a powerful contribution to weight, and another claims that they have 40+ therapies to help patients lose weight (Pence 490). What we see from this? Not every case is the same.

There is the fact that some people are able to "live strong" and, even though only about 10% of the population is able to work hard to limit calories, exercise vigorously, and consistently eat fresh foods, it demonstrates that the "ideal" is possible (Pence 491). However, the discovery that some people inherit a genetic variation that mutes their appetite makes this claim questionable. Ultimately, even though these people may be lucky, they are in no way superior or stand on higher ground than the average person because of what they inherited from their biological parents.

So, what does all of this mean for average people in our daily lives? Recognize that biology has a hand in everyone's weight, regardless of their diet or exercise regimen. Understand that it's difficult to maintain weight after a big gain or a big loss and that free will really only works best in not gaining weight in the first place. Realize that some drugs and diets can be helpful, but they often put you on dangerous ground because of the other ingredients in the drugs or nutritional deficiencies that come from depriving your body of what it needs. And most of all, remember that stigmas and shame don't help anyone, so get the education you can and treat people for what they are: people.

Textbook reference:

Pence, Gregory. Medical Ethics: Accounts of Ground-Breaking Cases. 9th ed., McGraw Hill, 2021. 

Don’t Let the Good Life Pass You By

What is the "good life" though? Does it involve sobriety or drinking/drugs in moderation or is it drowning out all sorrows/stress/worries using other stimulants? What is alcoholism? What is addiction? What causes them?

This discussion is an interesting, complex one that has probably either directly or indirectly affected everyone that will read this. Chapter 19 of Medical Ethics is on the ethical issues inn treating alcoholism and addiction. There are three different viewpoints presented by the author, and I think that the reality is most likely a mix of all of them.

The first question--is alcoholism/addiction a disease? If the answer to this question is yes, and the disease model of alcoholism is correct, then alcoholics fall down a 'rabbit hole' to alcoholism, and after taking their first drink their fate is sealed. Alcoholics Anonymous and Narcotics Anonymous believe strongly that, "alcoholism is an illness...which can never be cured. The concept of Alcoholics Anonymous is that alcoholics are sick people who can recover if they will follow a simple program" (Pence 462). The AA/NA model has developed a few distinct claims:

1. some people are more susceptible to alcoholism because it's a disease

2. a specific pattern develops during alcoholism, one of inevitable descent to rock bottom

3. the pain of withdrawal makes alcoholics so miserable that they continue drinking (or using drugs) to avoid their misery

4. victims lose all control over their use of substances (alcohol or drugs)

5. the damage of the above steps in the process escalates until victims hit the proverbial bottom, when they either die or reach out to others for help

They also adopt the stance that substance-abusers shouldn't be blamed for being sick and to do so would be to blame the victim. If it is a disease, these patients should also be treated as patients and should receive the same attention and care that other healthcare provides.

Next up is neuroscientists, who take a different stance. They claim that alcoholism/addiction is better considered and treated as an acquired disease of the brain (Pence 463). This is based initially on the fact that the first release of dopamine in the first exposure to the stimulant is higher than it will be in any subsequent high, thus leading to a pursuit of euphoria but never again achieving it to the same extent. There is also the matter of the antireward system being overactive in addicts, where an overwhelming feeling of uneasiness or general malaise follows the drug wearing off. So, even when the drug is no longer pleasurable and addicts no longer understand why they're taking the drug, this scientific specialty field claims that the brain has changed and now impairs many processes, leading to continued addiction.

Another hypothesized understanding of alcoholism/addiction comes from genetics. These scientists claim that alcoholism is a polygenic disorder (caused by an assortment of genes), as demonstrated in ~60% of alcoholism cases between 2004-2009 (Pence 464). Much of this is thought to be due to the underproduction of dehydrogenase (breaks down alcohol) and/or a genetic predisposition to alcohol resistance which leads to drinking larger amounts of alcohol without feeling as intoxicated. For some genetic diseases, a genetic mutation leads directly to a disease regardless of other factors; this is not the case for alcoholism. This fact raises some doubt, but geneticists say that "alcoholism is gene-based" and a person may be predisposed to a higher likelihood of becoming addicted, but isn't guaranteed to see that as part of their life. It is interesting to note though, that at this point much of the research is not yet able to definitively declare reasons as to why specific groups or cultures of people are more or less susceptible to becoming addicted (e.g. Native Americans and alcoholism) (Pence 465). 

When it comes to the ethics of alcoholism and addiction, there are again many different ideas. According to Kantian ethics, humans can give up on themselves and treat themselves as things--voluntarily destroying part of their essence (Pence 466). Humans are also "special" and that generates ethical considerations. Therefore, the disease model is flawed in treating people as things because it takes away their free will. Ethics based on Kantian models claim that AA and NA contradict themselves, because their programs assumes that the addict has the power to choose to be sober as well as claiming that people should be treated as objects (with a disease). 

Another philosopher, Herbert Fingarette, looked at studies and statistics and concluded that alcoholics have free will over their drinking, choose to be heavy drinkers, and make drinking a main focus of their lives (Pence 469). He also denied that alcoholism involves a progression of the disease, finding that many alcoholics learn to control their drinking and/or change their behavior if it begins to accelerate out of control. Fingarette said that many people who do not consider themselves alcoholics actually meet the criteria for alcoholism, therefore invalidating the disease model. Another contradiction (to AA/NA) pointed out here was that if the patient has a disease over which he has no control, what's the point of therapy or trying to live clean?

Sociologists focus elsewhere. From this vantage point, social factors explain a person's behavior better than anything else (Pence 468). Aspects such as ethnicity, socioeconomic status, social background, family structure/stability, etc. contribute directly to a variety of behaviors and explain many part of a person's life. 

Another approach, harm reduction, is in direct contrast to a moralistic approach by focusing on reducing bad consequences of deviant behavior rather than eliminating the behavior (Pence 469). This philosophy can be applied to many other moral issues like gun control, teen pregnancy, smoking, and, medical malpractice, among others. Harm reduction suggests that the addict controls some of the consequences of other actions and reducing some consequences of deviant behavior would allow them to have more control over their life.

The social justice model seeks answers to issues such as the thousands of addicted people living on the streets and using a wide variety of drugs (Pence 472). This can be compared to the Rawlsian ideas of justice, where a society is only just if the poor are better off than under a different system, which is currently false. Rawlsian justice also requires the basic structure of a society to discourage addictions rather than allow corporations to create addicted people and profit off of them, which is also not currently the case. There are many flaws with the current social and economic systems in place, and much must change before things can be considered just.

So, what? In my personal opinion, there are certain approaches that make more or less sense than others, but again, everyone's experiences are different. There's a lot to consider here, but I think it's important to look at the bigger picture and recognize that alcoholism and addiction are not positive conditions and that changes need to be made before there will be a just society that doesn't prey on people who may be more susceptible to these diseases/conditions/whatever you to call them.

Textbook reference:

Pence, Gregory. Medical Ethics: Accounts of Ground-Breaking Cases. 9th ed., McGraw Hill, 2021.

The Brainy Bunch

I realized today that we only have 6 class discussion periods left. 6! After writing 20 blog posts (including this one), 6 seems like a pretty small number. The end of the semester is rapidly approaching, and I have mixed feelings about upcoming finals.

This section in the textbook is on ethical issues in medical enhancement, including their effect on people with disabilities (Chapter 18). Medical advancement is an interesting topic, and one that seems to be highly contested in some sports. Is it smart/ethical to treat people who operate at less than "normal" (therapy) and/or give advancements to people who are functioning at a normal level so that they can be a step above that (enhancements)? Or is it a more intelligent decision to not provide this type of treatment to anyone? 

A relevant application of this question is found in the mass use of Ritalin and Adderall, highly addictive amphetamine salts that improve function for people with attention deficit/hyperactivity disorder (ADHD). For those who need the drugs to function, access to one of them is important. But what about the medical and law students who already have "normal" function but take Ritalin, Adderall, or modafinil (narcolepsy-countering stimulant) to gain an advantage and perform well under extremely stressful and demanding circumstances (Pence 447)? Is it ethical for them to fake the symptoms of ADHD and/or sleep disorders in order to gain access to stimulants that will improve their academic ability, or is it considered "cheating" like doping is in athletics?

The author of the text defines cheating as, "when the rules say competitors can't do X and someone secretly does X" (Pence 451). It is also discussed as a way of breaking the moral character in sporting and athletic events. So, for example, when athletes use growth hormones or blood with a higher red blood cell count as a way to gain an advantage in a competition, even though it is illegal to do so, it is considered cheating. It makes sense that competitors would want to do everything that they can do excel in their sport, but at what point is it no longer ethical? The Olympics used to ban the use of coaches, and advantages definitely still exist in wealthy athletes who don't have to work and can spend all of their time training, so are hormones just another advantage like these? Or are they somehow fundamentally worse? The chapter compares doping to an arms race, in that when athletes suspect that others are taking steroids they realize they are at a disadvantage and then also participate in doping (Pence 448). They do this to jostle for a positional advantage, putting them ahead of others who do not have the same assets in a competition. But, if everyone has access to the same advantage, it no longer puts them a step ahead. Justifying the use of steroids by saying that "everyone else does it" is using the ad populum argument, and is not a valid justification. Unfortunately, past research and surveys have shown that this mentality is dominating in some sports.

We know from experiences legalizing marijuana and prescription opioids that legalizing certain drugs does not decrease the number of people taking them, and would not help the current situation of doping in athletics. Legalizing steroids would only increase the arms race (Pence 454). Instead, we should be emphasizing that using steroids or doping with blood or other substances is cheating. The casual acceptance of cheating through doping and use of steroids is blatantly undermining fair competitions, and moves the focus from competing as you are to a mentality of "winning is everything"; which it is not. 

Therapeutic treatments, like growth hormones for those who need them and/or medications that restore a normal level of function (like Adderall or antidepressants), are not cheating. Therapy isn't cheating. Enhancements beyond normal functioning are. I agree with the author of the text on this one, that there are enhancements that are less harmful, like breast augmentation and botox injections, that fall into a category of their own because of a different intent. "Enhancements" like these are more for personal preference and do not directly give a substantial positional advantage to those who utilize them. 

The last section of this chapter mentions the effects of enhancements on people with disabilities and brings back up the question of, "What is normal and who defines it?" (Pence 455). Medical advancements have allowed people to overcome other obstacles previously defined as disabilities, like infertility or deafness. In the case of deafness, many Deaf parents (and others) advocate against the use of cochlear implants in children because it deprives them of access to the Deaf culture and introduces them solely into a Hearing world. This is interesting because those who argue for the use of implants claim that this argument contradicts the good of the family in a world that is more conducive to people who can hear. There are two gradients that apply here, that of a spectrum from lack of function to heightened function and one consisting of superficial defects to advantages in a person's life (Pence 456). There is a lot to consider when thinking about enhancements as they are related to people with disabilities. 

There are many things to consider in the general discussion on medical enhancements as well. However, the arguments against doping/using steroids, including using other drugs as stimulants when they're not needed for normal function, seem to be much clearer. As a bit of a side-note, the concept of "super-humans" has also been covered to a great extent in science fiction, especially in dystopian media. Are these advancements, whether in a singular person or in societies, considered ethical or even true enhancements? Will our society ever progress to a point where consistently taking enhancing drugs is the norm? 

Overall, many of the questions in this topic boil down to a sense of fairness and the importance of maintaining good, honest, moral character. And that's where I'm going to leave this discussion, at least for today. Leave a comment though, and let's chat about it! What are your thoughts/where do you stand?

Textbook reference:

Pence, Gregory. Medical Ethics: Accounts of Ground-Breaking Cases. 9th ed., McGraw Hill, 2021.

The Funeral to End All Funerals

After dealing with the US Election last week and having to defend so many of my beliefs to some family members who have wildly different stances than I do, seeing that the next chapter in the text is on the 2010 Patient Protection and Affordable Care Act resulted in a reaction very similar to this one.

It's been an exhausting week for everyone in the US I would imagine, regardless of political views or stance. On top of the pandemic and the ongoing stress of work, school, etc., there has been a considerable amount of political unrest, especially in the last couple of weeks. It's almost over though. I hope.

Anyways. I apologize for the tangent. The next topic we're discussing in this bioethics course is chapter 17 of Medical Ethics, titled, "Ethical Issues of the Patient Protection and Affordable Care Act". I know that healthcare in the US is a complex topic, and the author of the textbook did an excellent job providing a brief historical overview and arguments both for and against the ACA. Since a majority of the historical information presented in this chapter seemed to be more for context than for ethical consideration, I am going to dedicate this blog post to the moral and ethical dilemmas of the ACA since that is a more relevant topic at the moment. There are valid arguments on both sides of this, some points stronger than others; but today I'm not arguing, I'm simply presenting a case.

Opposing the ACA:

#1. Illegal Immigrants
In short, forcing employers to provide medical coverage to illegal workers will break the bank (Pence 426). Some states are currently spending upwards of $1 billion on medical care for illegal immigrants. America can't afford to open its borders and give away medical coverage and jobs to everyone who wants to enter. This quickly becomes a slippery slope, in that if we provide care to some people in some cases, where is the line going to be drawn? The green card and "naturalization" processes are long, drawn-out, and difficult. Yet the Trump administration was dedicated to making it more difficult. Some Americans without medical coverage may resent the fact that undocumented workers can get some medical benefits. 

#2. Federal Bureaucracy is Inefficient 
Critics of the ACA claim that it will create an expanded bureaucracy in healthcare in the US (Pence 428). They also predict that it will become another end stage renal disease program, one with runaway costs, no incentives for physicians or patients to minimize them, and no real accountability. What is the role of the federal government in medical care and how large should it be allowed to grow? Many of the states resisting Medicaid expansion are more fiscally conservative, and presently many states must choose between fully funding universities, Medicaid, or prisons, due to the fact that citizens consistently vote against raising taxes, and therefore states are dealing with a zero-sum budget.

#3. Government Cannot Make Medical Finance Rational
A long-standing struggle of balance exists between equality and liberty, and while involuntary taxation is abhorrent to some, transfers of income mean  taxation. For a universal coverage plan to work, patients would not be allowed to opt out of the system, which is a problem that eventually undermined the Canadian system. This stance suggests that instead of socialized, or publicly owned, medicine, the US needs a real market of supply and demand because the ACA brings too much equality at the expense of personal liberty.

#'s 4 & 5. Health Care is Not a Right
The problem with thinking of healthcare as a right is that America was founded on rights to be left alone, to pursue happiness, and to function generally without governmental interference (Pence 430). This freedom is different from a "freedom to" which functions as a right to a service from others, or an entitlement. States will eventually be in a bind when voters refuse tax increases but demand more services. There is also the issue of what qualifies as basic medical care, and what coverage should be provided and what should not--it all blends together. This also leads to problems along the edges, like defining citizenship and eligibility, as well as the rights of someone who has recently become a citizen versus someone who has been paying into the system for a lifetime. There is also the obstacle of small, inefficient hospitals in areas where the citizens claim their existence as a right even though they are costly and inefficient.

The author also poses the consideration that the more health care is seen as a right, the more people will tend to seek medical care in more circumstances (Pence 433). It also exists as an issue, that Medicare generally extends the lifespan, and the oldest members of a population are the most costly. It is interesting to note that, as it currently stands, Medicare will run out of money in 2026 and Social Security in 2033. It is not difficult to justify covering most of the adult, working poor, but covering the last few percent is expensive because those patients suffer more severe conditions and a "just limit" cannot be fully defined.

#6. Intergenerational Injustice
Opponents of the ACA state that funding the ACA will create a massive battle of intergenerational justice, starting with the Baby Boomers. Currently, today's young workers pay for the Medicare benefits going to today's elderly, opposing the claim that they paid for Medicare while they were working (Pence 436). The ACA will sentence all younger generations to what could be considered tax slavery to pay for more medical care for more seniors who are living increasingly longer lives. States refusing to expand Medicaid might be doing the young a favor by refusing to establish an entitlement of universal medical coverage and yoking them to the tax burden. 

Favoring the ACA:

#1. Illegal Immigrants
Many Americans believe that illegal workers don't pay FICA or income taxes, when in fact they do. The IRS issues identification numbers to illegal workers (gangsters, drug runners, illegal immigrants, etc.) to collect the taxes on their paychecks. Studies in 2013 discovered that immigrants created a surplus in Medicare that far outweighed the deficit from established Americans (Pence 427). Providing illegal immigrants a legal pathway to citizenship would help finance the ACA, and with controlled, regulated, legal immigration, the US population could grow to nearly 400 million by 2050.

#2. Greater Efficiency

The ACA could eliminate the overhead, profit, and waste of multiple private insurers to cover medical care for poor people (Pence 427). Current costs of the ACA are predicted to be 25% less than the original estimate because not all states have expanded their Medicaid coverage. 

#3. Making Medicine Rational
The ACA banned insurance companies from including experience ratings and assumes that coverage is a moral enterprise of sharing risk to help others who may be less fortunate (Pence 429). It also attempts to cover and control costs by setting up systems to encourage evidence-based medicine. For example, Medicare currently reimburses physicians for almost any treatment that works or that might work as opposed to some private insurance companies that reimburse much higher for procedures than for preventative care. The ACA also sets up review panels to rationally evaluate what, if any, intervention/treatment is necessary or will work best for a particular patient.

#4. Minimal Health Care is a Right
If justice is indeed fairness, as claimed by philosopher John Rawls, then it requires universal medical coverage because justice applies to the basic structure of society, including healthcare (Pence 431). Rawls understood that the world is naturally unfair, but claimed that a just government would reduce natural inequality while preserving liberty. Prior to the ACA, 46 million Americans lacked medical coverage, which is a massive and unjust structural inequality. The current American medical system is obviously unjust because the poor are not better off under it than under an egalitarian system where care would be more equal. As for a real market approach to controlled medical finance, it would not hold up. There would be no medical insurance, no reimbursement, and prices would tumble. In a true market, medical professionals would stop working with patients to overcome disease, but rather both would be working against the other in an attempt to achieve financial gain. It is also true that if healthcare wasn't subsidized, many people who could afford care would make foolish decisions (e.g., opting for a car instead of a hip replacement, etc.), similar to those that people without insurance are facing today.

#5. Costs Can Be Controlled
In 2007, the top 10 pharmaceutical companies made more profits than the other 490 Fortune 500 companies and medical device manufacturers also made massive profits (Pence 435). Taxing these companies to fund medical services for more patients is not an unreasonable goal. Fixing Medicare and Social Security is feasible, incremental changes will have to be implemented, but they are projected to produce positive long-term results. For example, the age of eligibility for Social Security has been raised, the Medicare payroll tax has increased for married, employed couples, and the amount that can be sheltered from taxes in spending accounts has dropped which results in an increase in taxes. The ACA also raised the tax for the wealthy for hospitals, as well as the taxes on capital gains, royalties, and dividends. None of these new taxes are earth-shattering or much of a burden to those paying them. Without change, Medicare would have continued increasing in costs, so it was necessary to make some changes so that millions of Americans would not have to worry about a total lack of medical coverage or paying more costly premiums each year for lesser coverage.

#6. No Intergenerational Injustice
Proponents of the ACA claim that no intergenerational injustice exists (Pence 437). Four claims are made here by the author, that under a veil of ignorance everyone would choose to insure themselves against being injured and having no coverage, many young people without insurance are currently not paying anything into the system, some seniors who make upwards of $250,000/year should not be provided free Medicare, and not expanding Medicare is unjust and violates the idea that the whole country is creating an environment for community rating.

In conclusion? I'm not sure. The author concludes that, in the long run, a national, single-payer system is the only sustainable option (Pence 440). In other words, a system where everyone receives comprehensive coverage regardless of their ability to pay, one where the single-payer is the government. There is also a more moderate proposal of a "public option", where those Americans who currently have coverage through their employers would retain that coverage while enrolling everyone else in a government-regulated plan. In essence, healthcare is complicated and there is no one perfect solution. It is important to understand what goes into the various plans though and to not jump onto bandwagons just because certain people are endorsing them. Personal education and consideration will always be important, especially in a democratic country where the voters make many of the decisions.

Textbook reference:

Pence, Gregory. Medical Ethics: Accounts of Ground-Breaking Cases. 9th ed., McGraw Hill, 2021.

 

You’ve Changed, Man

Learning about diseases, viral or otherwise, often leads to sentiments similar to these.

Chapter 16 in Medical Ethics focuses on the ethical issues in stopping the global spread of infectious diseases. This chapter focuses mostly on viruses, subcellular pathogenic agents that cause many infections in humans and are prone to mutation. One of the other courses that I am enrolled in this semester is on communicable disease control, so this chapter contained very familiar content. The non-ethical bits anyway. Except maybe that we've discussed several times in my diseases course how the continued global population growth will continue to contribute to emerging infections, epidemics, pandemics, etc. as people continue to live closer together and keep moving into spaces previously and naturally occupied by other animals. That is a moral/ethical issue. Anyways. 

The main portion of this chapter is on HIV and the HIV/AIDS epidemic(s) that caused a major uproar in the 1980s and is still ongoing in many nations. The history of HIV, especially in America, is closely entwined with LGBT rights and activism, and the chapter reflects that. The ethical issues that the author discusses when it comes to HIV are homosexuality and HIV exceptionalism. The main issues around homosexuality and HIV are related to stigma and shame when it comes to viral spread and screening and whether or not certain measures were considered homophobic or discriminatory. This aligns with exceptionalism, in that many people believed contact tracing and treatment research were unnecessary because it was only a "gay disease" and heterosexuals were not at risk. It took public deaths and irrefutable evidence to convince people otherwise. 

The author goes on to discuss various views on stopping the spread of HIV globally, but comes to the conclusion that the best strategy is in educational prevention. It takes religion, morality, and triage out of the argument, and allows people to be treated equally and shows that when given education and access to treatment options that the quality of life for people who have been exposed to HIV improves dramatically. 

Similar arguments exist for other outbreaks and pandemics, including Zika, Ebola, and the current and ongoing SARS-CoV-2 pandemic. The influence of updated public health practices, medical research, epidemiological understanding, the internet, and social media have created a much improved environment to deal with future outbreaks. With all that has gone on in the past and how much we have learned, one would think that our ability to handle the current pandemic would be much better than it is.

Textbook reference:

Pence, Gregory. Medical Ethics: Accounts of Ground-Breaking Cases. 9th ed., McGraw Hill, 2021.

Whenever You’re Ready

All things genetics? Yes, please! My current career goal is to become a genetic counselor, so talking about genetics, genetic testing, and the ethics surrounding it, is all right up my alley of interest. This is actually the topic that I chose to focus my term paper on as well. I guess you could say that this is something I am invested in.

Chapter 15 in Medical Ethics is all about the ethical issues in pre-symptomatic testing for genetic disease, and discusses two main themes: (1) is it wise to test in advance for genetic diseases, and (2) can at-risk people do anything to avoid genetic diseases (Pence 362)? 

The chapter opens with the stories of Angelina Jolie and her testing positive for a BRCA mutation and Nancy Wexler and her research on Huntington's disease. Both stories offer interesting perspectives on genetic testing and semi-opposing views--is it more important to have pre-symptomatic testing done in order to prepare for what's coming and take potential preventative action or should we be advocating against testing and taking a stance against it? Is personal genetic information life-altering in positive or negative ways? And who gets to decide? The third case presented is that of Maria Lopez, a woman living in East Harlem who had Type 2 diabetes in 2006. In this case, the author brings up the question of responsibility and whether or not knowledge of a disease will change a person's actions and whether or not they can be expected to alter their routines to accommodate a new diagnosis/new information. The last case discusses testing for Alzheimer's disease and the risks associated with inheriting the ApoE4 gene. This case is difficult mainly because of a lack of knowledge of how to prevent Alzheimer's (Pence 369).

A large and dark chapter in genetics history is the eugenics movement. Not to say that it's completely over, there are still advocates of its beliefs that are around today. The classic eugenics movement hoped to improve hereditary characteristics through voluntary, selective breeding (Pence 365). In Charles Darwin's original work he talked about "survival of the fittest", and by this meant "best adapted" or an organism's fit to its environment. This was misinterpreted by social Darwinists who applied this concept to social ideology, and from there it became a white, elitist movement. It caught on and stuck so well because of widespread bigotry, and flourished in the US from 1905-1935 (Pence 365). Eugenics included the sterilization of people characterized as "mental defectives" in Nazi Germany, and the "retarded and criminally insane" in America. Several large-scale cases and legislative acts reflected some of the inhumane tragedies that were allowed during this time period and the few decades that followed (e.g. Buck v. Bell) (Pence 366). 

Like the title of this post suggests, timing can be everything. And how do we know if we are ready to receive potentially life-altering information? Will we ever really be ready?

There are many ethical issues raised by genetic testing. The first one listed in this chapter is preventing disease. Regardless of prevention measures taken, some people will still develop the disease associated with the genetic mutation/disorder they have. So, is pre-testing worth it? Or will people simply develop a fatalistic attitude and give up on goals and future achievements? It is also interesting to consider testing as a self-interest or only when looking for good news. Knowing your personal genetic information could be highly beneficial and allow you to take preventative measures, but is the knowledge and possibility of earlier preventative measures worth the weight of the knowledge? And what happens when you get an unexpected result and/or are unable to handle such difficult news? What about your family? A genetic test isn't only for you, any results that you receive also have indications for your family, both immediate and extended. So, is it important to be tested for your family's sake; do you all get tested together? Or does nobody get tested? Can one parent test a child in order to find out if the other parent is affected? Should children be tested at all? Should people be allowed to have testing done in order to determine paternity or find "long-lost" siblings or other family members? And coming back to an earlier question that I touched on, what about personal responsibility for diseases and/or acquiring a "sick" identity after receiving a positive test result? At what point (if at all) do the positives outweigh the negatives? 

It's important to note here that genetic testing really should only be offered and available to the public when good genetic counseling accompanies it. That is the main issue with direct to consumer (DTC) genetic testing, like 23andMe or other similar companies. If a positive result with major implications is found, the patient has nobody to talk to or work through the news with--someone who understands the science, the medical implications of the positive result, and has psychosocial training to help de-escalate the situation and provide proper counseling. Ordering a DTC test is a relatively popular thing to do, they're common as gifts or as something to do with family. The phrase that best fits this action though, is "be careful what you wish for". I guess this is my little plug for my (hopefully) future career--always talk to a genetic counselor when it comes to genetic testing. There is a reason there are professionals in the field, and it's not to direct or convince people to have testing done or to take certain measures, it's to help patients by providing non-directive counseling and assist them in understanding what's really going on. 

A couple other ethical considerations brought up in this chapter involve the future of genetic research and genetics in general. For 11 years (2002-2013), Myriad Genetics had a patent on the BRCA gene and charged up to $3,000 for genetic testing. The U.S. Supreme Court overturned a decision by the Patent Office on this matter though, and genetic testing has exploded outward since then. Looking forward, someday geneticists and physicians hope to have some type of personalized medicine system in place where a patient's genetics will benefit them in all areas of health. Recent research has also allowed for mitochondrial donation therapy, where a mitochondrial donor is able to replace the mitochondrial genes (37 total) that can cause devastating heritable diseases. This also raises the question of genetic engineering and "designer babies" alongside the potentially helpful gene therapy and embryo repair. Where are the lines drawn? Will new lines need to be drawn as research moves forward and more is discovered and/or made possible through new technology? How will we know what questions to ask and where to regulate experimentation and where to encourage it?

Genetics is a complicated issue, albeit one I'm very interested in and passionate about. As with many other ethical issues, it raises a multitude of questions I don't have complete answers for. I am hopeful that my future training and experiences will help to decode some of these, but for now I'll remain fascinated and dedicated to learning as much as I can about the building blocks of life as we know it.

Textbook reference:

Pence, Gregory. Medical Ethics: Accounts of Ground-Breaking Cases. 9th ed., McGraw Hill, 2021.