Health Care Distribution

1
Health Care Distribution

• PHL281Y Bioethics
• Summer 2005 University of Toronto
• www.chass.utoronto.ca/kirstin

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Overview

• Human Capabilities (Nussbaum)
• Context of Health Care Decisions Justice
• Health Care Distribution (Gutmann)
• Quebec Case Medicare

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Motivation

• We urgently need a conception of the human being
  and human functioning in public policy (86)

4
Quality of Life Assessments

• 3 Current Options
• GNP per capita
• No concern for distribution (vast inequalities)
• No concern for other human goods (infant
  mortality, access to education, racial or gender
  relations, political freedoms)
• Ex/ United Arab Emirates - 10th highest GNP while
  67th for life quality (literacy 55, maternal
  mortality 130/100,000, 6 labour force female,
  ratio females to males 48100)

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Quality of Life Assessments

• Utility measures - polling people on preference
  satisfaction
• Not always reliable indicators of what a person
  really needs (preferences are highly malleable)
• Results often support status quo and oppose
  significant change
• Group preference satisfaction - tradition
• Can be quite disastrous for women (Ex/
  menstruation taboos)

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Nussbaum

• Begin with the human being (61)
• Philosophical accounts of human nature (Ex/
  Rousseau)
• Allegedly unbiased - privilege power,
  oppression, exclusion marginalization
• Recent biased list of capabilities (Ex/ IQ
  testing)
• Yet
• We will only solve our problems if we see them
  as human problems arising out of a special
  situation, and we shall not solve them if we see
  them as African problems, generated by our being
  somehow unlike others - K.Appiah (In Nussbaum,
  63)
• Universalist and Essentialist - some
  capabilities and functions are more central, more
  at the core of human life, than others (63)
• 3 encounters with relativism/anti-essentialism
  (64-67)

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Nussbaum

• Question - What are the characteristic activities
  of the human being? What must be present if we
  are to acknowledge a given life as human?
• What changes or transitions are compatible with
  continued existence of that being as a member of
  the human kind, and what are not? (72)
• Often asked in medical decisions about death,
  illness and impairment

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Methodology

• Experiential, historical inquiry
• International
• Normative/evaluative (not value-neutral)
• Tentative, open-ended
• Overlapping social consensus
• Fair and reasonable procedures of achieving
  consensus
• Heterogenous list (limits against which we press
  and capabilities through which we aspire)
• Like personhood accounts but more
  species-specific and less exclusive

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Limits and Capabilities of HumansThreshold 1
Human Life

• Mortality
• The Human Body
• Hunger and thirst
• Shelter
• Sexual desire
• Mobility
• Capacity for Pleasure and Pain
• Cognitive Capability
• Early Infant Development
• Practical Reason
• Affiliation with Other Beings
• Relatedness with Other Species and Nature
• Humour and Play
• Separateness
• Strong Separateness

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Threshold 2 Good Human Life

• Life of normal length
• Health (food, shelter, sexual satisfaction,
  mobility)
• No unnecessary and non-beneficial pain
  pleasurable experiences
• Use of the senses (imagination, reason
  cultivated by adequate education, freedom of
  expression and religion)
• Attachment to others (love)
• Ability to form a critical conception of the good
  (employment, political participation)
• Social interaction (freedom of assembly, freedom
  of speech)
• Relationship to animals, plants, nature
• Ability to laugh, play and enjoy recreational
  activities
• Non-interference with regard to definitive
  personal choices (marriage, childbearing, sexual
  expression, speech, employment)
• 10a.Privacy (personal property)

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Objections and Replies

• 1. Neglect of historical and cultural differences
• Any attempt to pick out some elements of human
  life as more fundamental than othersis bound to
  be insufficiently respectful of actual historical
  and cultural differences (70)
• Usually at the expense of minority understandings
  (many historical examples)
• Reply 1 Would an ethics based on local
  differences do any better? Misses out on common
  ground and shared capabilities
• Reply 2 Not a necessary condition

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Objections and Replies

• 2. Neglect of autonomy
• By determining in advance what elements of human
  life have most importance, the universalist
  project fails to respect the right of people to
  choose a plan of life according to their own
  lights (71)
• Reply 1 list of capabilities (not actual
  functions) which leaves much room for choice
• Examples Fasting, Celibacy
• Reply 2 choice is built into the list as
  practical reasoning (capability for choice)
• Reply 3 choice is not mere spontaneity
  (independent of material and social conditions)

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Objections and Replies

• 3. Prejudicial Application
• Powerless can be excluded all too easily
• Reply 1 Better off without it? No - Would have
  been easier to exclude women and slaves without
  it
• Reply 2 Not a necessary condition
• Reply 3 Easier to exclude people on classic
  accounts of personhood or rational beings

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Objections and Replies

• 4. One Standard or Two?
• Men and women have same functions and
  capabilities but they should be exercised in
  different spheres
• Reply Separate tends not to be equal
• Restriction of women to private sphere limits the
  development of all capabilities (so internally
  inconsistent)
• Also, what basis for assuming different spheres?
  Biological? Social facts?

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Objections and Replies

• B. List of functions and capabilities should be
  different for men and women because they are
  different
• Reply 1 Not supported by scientific evidence
• Reply 2 Even if it were supported by scientific
  evidence, likely statistical distribution
  differences - not threshold differences (and even
  if threshold - only on narrow functions)
• Reply 3 Not practically possible to support this
  position with good scientific evidence given
  socialization (high potential error in testing -
  err on side of caution and assume all individuals
  have basic capabilities)

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Nussbaum

• Human capabilities exert a moral claim that they
  should be developed
• Underlying basis for accounts of human rights
• Many social structures prevent people from
  expressing these capabilities
• Ex/ Restrictions on womens education
• Ex/ Restricted access to health care

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Health Care Distribution

• The neglected principle Justice
• Decision-making in health care
• Macro level - governments
• Ex/ Health care funding
• Meso level - health districts, hospitals
• Ex/ Organ waiting lists
• Micro level physicians, nurses
• Ex/ Treating smokers

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Liberalism

• Basic Introduction to Rawls Justice as
  Fairness
• Liberty
• Equality
• Of Respect
• Of Opportunity

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Health Care

• Liberty Right Only
• Right to Minimal Care
• Right to Equal Access
• Right to Equal Health

Liberty
Equality
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4 Options

• Liberty Right Only
• No restrictions on accessing/providing healthcare
• No claim to assistance from others
• Buy what you can afford
• No government involvement
• Free market all goods are subjective, no way of
  ranking desires so use the market to order and
  rank priorities
• Objections
• Duty to aid when no great cost?
• Unfair to unlucky (persistent existing
  inequalities)
• Not all goods are subjective health is an
  objective good that all people need (Nussbaum)

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4 Options

• Right to Minimal Care
• Some government involvement
• Example USA
• Objection
• Costs (13.9GDP vs. 9.5GDP)
• (later)

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4 Options

• Right to Equal Access
• Single-tier (no private sphere)
• Universal coverage
• Not specified particular provisions or total
  level of health care that should be available
• Equality of effective opportunity to receive care
  (not merely equality of formal legal access)
• Example Canada
• Objection
• Too paternalistic (autonomy/liberty is limited)
• Those people with discretionary income
• Those health care providers who wish to sell
  their services outside the system
• Reply
• Not paternalistic if democratically chosen (our
  own choice to restrict liberty) fair process
• Not taking away gross income if no entitlement

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4 Options

• Right to Equal Health
• Fully egalitarian
• Aim equal outcomes/results
• Objections
• Excessively paternalistic - not enough regard for
  individual autonomy/freedom
• To everybody
• Costs
• Too highly prioritizes health as a good
• Dismal society if all health needs met and no
  other goods (quality of life)

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Gutmann

• Rejects options 1 and 4, focuses on 2 and 3
• Health care is different from other consumer
  goods
• Argues for option 3 (right to equal access)
  because it makes better sense than option 2
  (right to minimal care) on three values
• Equal Opportunity
• Moral Equivalence of Pain
• Self-Respect

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1. Equal Opportunity

• Relationship between health and equal opportunity
  is different than the relationship between most
  other consumer goods and equal opportunity
• Like police protection and childhood education,
  provides necessary conditions for equal
  opportunity
• Sometimes used to justify options 1 and 2, but if
  taken seriously requires option 3

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2. Moral Equivalence of Pain

• Pain and suffering are always bad (and are
  equally bad in any person)
• Option 3 takes this seriously
• The pain of the poor is less bad in 1 and 2

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3. Self-Respect

• 2-tier system undermines self-respect of poor
• Example waiting in line while others bypass
• Example self-respect and suffrage (equality)

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Gutmann

• Principle of Equal Access to Health Care
• Demands that every person who shares the same
  type and degree of health need must be given an
  equally effective chance of receiving appropriate
  treatment of equal quality so long as that
  treatment is available to anyone. (542)
• Prudent aim higher minimum in USA
• Irony money and nonessential goods (egalitarian
  principle in an inegalitarian society)

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Other Questions

• Liable for voluntary risk?
• Empirical Question better physicians migrate to
  higher tier if two-tier?

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Canada Health Act

• Public Administration the administration of the
  health care insurance plan of a province or
  territory must be carried out on a non-profit
  basis by a public authority
• Comprehensiveness all medically necessary
  services provided by hospitals and doctors must
  be insured
• Universality all insured persons in the province
  or territory must be entitled to public health
  insurance coverage on uniform terms and
  conditions
• Portability coverage for insured services must
  be maintained when an insured person moves or
  travels within Canada or travels outside the
  country and
• Accessibility reasonable access by insured
  persons to medically necessary hospital and
  physician services must be unimpeded by financial
  or other barriers.
• - Government of Canada

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Recent Challenge - Zeliotis/Chaoulli

• Quebec patient - George Zeliotis argued that his
  constitutional rights to life, liberty and
  security of the person were violated by a
  year-long wait for a hip replacement
• Zeliotis brought his fight to the Supreme Court
  along with a physician, Dr. Jacques Chaoulli, who
  wanted the right to set up a private medical
  business
• They asked the court to overturn portions of the
  Quebec Health Insurance Act and Quebec Hospital
  Insurance Act that prohibit buying private health
  insurance for medically necessary services
• The Supreme Court of Canada has struck down
  Quebec's ban on using private insurance for
  services covered under Medicare

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Zeliotis/Chaoulli

• Four of the court's seven judges involved in the
  decision wrote that the ban was in violation of
  the province's Chart of Rights
• "The evidence in this case shows that delays in
  the public health care system are widespread, and
  that, in some serious cases, patients die as a
  result of waiting lists for public health care."
• "The evidence also demonstrates that the
  prohibition against private health insurance and
  its consequence of denying people vital health
  care result in physical and psychological
  suffering that meets a threshold test of
  seriousness."
• But the country's top court was divided on
  whether the Canadian Charter of Rights has been
  violated. One judge abstained so the vote was
  split 3-3.
• Dr. Albert Schumacher, president of the Canadian
  Medical Association, says the ruling could
  "fundamentally change the very foundations of
  Medicare as we now know it.''
• - Sources CTV CBC News

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Analysis

• On what basis do we justify our current health
  care system?
• Options
• Better funding current system
• 2-tier system

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Summary

• Human Capabilities (Nussbaum)
• Context of health care decisions justice
• Balancing values
• Health Care Distribution (Gutmann)
• Quebec Case Medicare

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Next class

• Limits of bioethics, course themes
• Review for final, structure of final
• No posted lecture notes
• Course evaluations
• Reminder Final Exam
• Monday, Aug.15th 7-10pm
• GB 304

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Contact

• Prof. Kirstin Borgerson
• Room 359S Munk Centre
• Office Hours Tuesday 3-5pm and by appointment
• Course Website www.chass.utoronto.ca/kirstin
• Email kirstin_at_chass.utoronto.ca