Should medical care be withheld from those individuals that have made "poor lifestyle choices"? (Managed Care)

Should medical care be withheld from those individuals that have made "poor lifestyle choices"? (Managed Care)Colin SherrillAndy Von CanonBINF 705

Approach • Background • Definitions and Analysis • Viewpoints & Perspective • Ethical Implications • Conclusions • Pro • Con • Decision • Reality

Background/Why • Very Complex Problem – One of the most discussed areas of ethics • Most ethics discussions avoid the Patient Responsibility from the patient’s viewpoint

Diabetes • Type 1, Autoimmune disease • The immune system attacks the insulin-producing beta cells in the pancreas and destroys them. • Type 1 diabetes accounts for about 5 to 10 percent of diagnosed diabetes in the United States. • It develops most often in children and young adults, but can appear at any age. • Type 2, Acquired • This form of diabetes is associated with older age, obesity, family history of diabetes, previous history of gestational diabetes, physical inactivity, and ethnicity. • About 80 percent of people with type 2 diabetes are overweight. • Type 2 diabetes accounts for 90 to 95 percent of diagnosed diabetes in the United States. • The symptoms of type 2 diabetes develop gradually. Their onset is not as sudden as in type 1 diabetes. • This is interesting for a few reasons • This is not necessarily a lifestyle choice. • A social stigma exists for this disease complicating decisions about research. • Does it matter how one acquires a disease? http://chinese-school.netfirms.com/diabetes-types.html

Smoking • The risks of smoking • Smoking up to the time of any surgery increases cardiac and pulmonary complications, impairs tissue healing, and is associated with more infections and other complications at the surgical site. • Acquire lung, throat, and other cancers. • “Smoking is, however, unique in that its associated risk can be reduced substantially within a short period.” -Matthew Peters • Enjoying a cigarette before the operation could suck money out of the healthcare system – and thereby worsen someone else’s treatment. • thetruth.com lists many risks associated with smoking. • Slipping down the slope • In 2006, a UK primary care trust announced that it would remove smokers from its surgery waiting lists to cut costs. • Should we deny medical attention to many people with other bad habits? • “Do patients have a general obligation to get healthy as a condition of receiving treatment? Patients are not required to visit fitness clubs for eight weeks, lose 25 pounds, or take drugs to lower blood pressure before surgery.” -Leonard Glantz • What about alcoholics, drug users, etc? Should everyone be screened for every bad habit before surgery? • Listening to your doctor • Before surgery, you don’t drink water, take your pills, don’t drink alcohol. Where does their authority end? When do “doctor’s orders” become “doctor’s advice?” • We do accept a certain amount of responsibility before surgery, as we ought to. http://www.newscientist.com/blog/shortsharpscience/2007/01/do-smokers-deserve-equal-medical-care.html

STDs • There are numerous medical risks associated with a promiscuous lifestyle. • Chlamydia, HIV, HPV, Herpes, Gonorrhea, Hepatitis, Syphilis, etc. • Constantly educated about them. • DARE, AdCouncil, Sex Ed. • Statistics • One in five people in the United States has an STD. • More than half of HIV infections occur in people under 25. Does the education work? • Two-thirds of all STDs occur in people 25 years of age or younger. • One in four new STD infections occur in teenagers. • Cervical cancer in women is linked to HPV. • STDs, other than HIV, cost about $8 billion each year to diagnose and treat ASHA is a trusted partner with the Centers for Disease Control and Prevention and operates the national AIDS, STD and Immunization Hotlines. • One in five Americans have genital herpes, yet 90 percent of those with herpes are unaware they have it. • At least one in four Americans will contract an STD at some point in their lives. • Where is the responsibility? • How much money should go to educate the public? How much to treat the diseases? How much to research? • If these diseases were passed some other way, would that make a difference? http://www.coolnurse.com/std2.htm

Obesity • Prevalence. • Approximately 127 million adults in the U.S. are overweight, 60 million obese, and 9 million severely obese. • Currently, 64.5 percent of U.S. adults, age 20 years and older, are overweight and 30.5 percent are obese. • Problems • Obesity increases the risk of illness from about 30 serious medical conditions. • Obesity is associated with increases in deaths from all-causes. • Ethics • Weight loss of about 10% of body weight, for persons with overweight or obesity, can improve some obesity-related medical conditions including diabetes and hypertension. • Does this mean that the obese are responsible for part of their health related issues? http://www.obesity.org/subs/fastfacts/Health_Effects.shtml

Money • Ought money even influence our ethical decision? • Does the correct thing to do depend on the cost? • That is generally how we live our lives anyway, so it ought to be considered. • Healthcare costs • Dr. Jeffery Burnich said, “To help lower your health costs, promote wellness programs.” • The most effective “wellness programs” are: • Stress management, weight management, physical fitness, nutrition, medical self-care, and smoking cessation. • Smokers generate 31% higher claim costs than nonsmokers. • Medical expenditures were $1.4 trillion in 2000, and are expected to reach $2 trillion in 2010. Should we focus on lowering this number? • Deciding what money goes where is a big question. • It is an ethical question to determine how to distribute money among research, treatment, wellness programs, advertising, and money for bioinformatic graduate students. http://www.ncpers.org/PastConf/2003/Ann_Conf/2003annual_11.asp

Definitions • Medical Care (Health Care) • Health care or healthcare is the prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered by the medical, nursing, and allied health professions. • Lifestyle • In sociology, a lifestyle is the way a person (or a group) lives. This includes patterns of social relations, consumption, entertainment, and dress. A lifestyle typically also reflects an individual's attitudes, values or worldview. Having a specific "lifestyle" can be described as patterns of behavior based on alternatives given and how easy it is to make this choice over others given • Poor Choice • Choice consists of that mental process of thinking involved with the process of judging the merits of multiple options and selecting one for action. In this case one of inferior or one leading to bad consequences. • Rights • a right is the legal or moral entitlement to do or refrain from doing something or to obtain or refrain from obtaining an action, thing or recognition in civil society. • Duty • applied to any action (or course of action) which is regarded as morally incumbent , applied to any action (or course of action) which is regarded as morally incumbent • Privileges • is an honor, or permissive activity granted by another person or a government. A privilege is not a right and in some cases can be revoked

Definitions • Managed Care • Plan to control employer's health care cost through the introduction of practice guidelines or protocols for health care providers, and to improve the methods used by employers and employees to select health care providers. The goal of the plan is to create a financial accounting system in order to manage the impact of medical treatment on the patient's clinical response and quality of life. Once such a system is created, the employer and the employee will be better able to judge which health provider is more effective and efficient. (Answers.com) • Finally, managed care is generally more restrictive on the types of "big ticket items" it will pay for. Many exclude transplants all together. Most have annual caps on the amount of prescription drugs they will pay for. The patient must make up the difference. To offer a real incentive for cost containment, many HMO primary care physicians are given a "budget" that varies according to how many patients they oversee. If they are under their "budget," then they receive all or some of the difference. Thus, the physician has a financial interest in holding down the number of tests and expensive procedures s/he allows you to have. (IJ of Politics and Ethics)

Viewpoints and Perspective • Legal (US) • Current laws are vague in that the current legality of withholding healthcare and level of care falls more in the “errors/omissions” and malpractice with avoidance of legal obligation to unlimited care. • Right Versus Privilege • Constitutionally healthcare is not a right or obligation of the government. • In the case of justice, we are required to follow due process in order to determine just limits on health care that will be generally accepted. • Medical • The “Hippocratic Oath” • The physician’s ethical duty is to first do no harm to the patient, the practice or society. • Ethical • Traditional • Social • Economic • health care is over 15% of our economy • Chronic diseases lead to extreme levels of costs on a individual basis • who is responsible for these costs

Viewpoints and Perspective • A traditional view is that improvements in health result from advancements in medical science. The medical model of health focuses on the eradication of illness through diagnosis and effective treatment. • In contrast, the social model of health places emphasis on changes that can be made in society and in people's own lifestyles to make the population healthier. It defines illness from the point of view of the individual's functioning within their society rather than by monitoring for changes in biological or physiological signs. • One question is whether every person has a fundamental right to have health care provided to them by their government. Those who feel that health care is a right believe that societies which are able to provide health care have a duty to do so equally for all of their citizens. The United Nations' Universal Declaration of Human Rights enumerates medical care as a right of all people. • The opposing school of thought is that health care can become an entitlement if government specify it as a right of citizenship, but that it is not a fundamental right of all people. Furthermore, that it violates fundamental individual rights because it is a non-essential wealth redistribution. Source: Wikipedia

Traditional “Poor” Lifestyles • Personal Self Management • Diet and Eating Habits • Lack of Exercise • Genetics • Smoking • Alcohol Abuse • Drug Abuse

Potential “Poor Lifestyles” • Voluntary Occupational “Lifestyles” • Soldier • Fireman • Policeman • Race Care Driver • All voluntary • High Risk for Physical Trauma • High Risk for Mental and Substance Abuse Issues • Most injuries require substantial costs

Effects • “Poor Lifestyle” Effects • Medical • Diabetes • Blood Sugar • Leads to Neuropathy, transplant • Obesity • Eating Habits • Leads to heart disease and numerous health issues • Cancer • Heart Condition • Addiction • Traumatic Physical Injuries • High costs with long term rehabilitation

Analysis • Difficulty lies in the establishment of support for several areas to include: • Is healthcare a “right or privilege” • Right involves more responsibility by society and unlimited access • Privilege involves more responsibility on the patient and possible restrictions • Poor “Life Styles” create slippery slope for cause and effect as well as who defines poor “life style” • As medical science evolves the level of diagnosis and treatment will increase regardless of costs • Costs are real

Ethical Viewpoints • Obviously one important part of the health care debate is whether or not a citizen of a country has a right to health care. If he or she does, then it is the government's correlative duty to provide this good to the individual. (4) Thus, if all citizens have a right to health care, then the government has the correlative duty to provide it. Therefore, it is an important question whether or not individuals have a right to health care. • To this end let us examine two theories for the basis of human rights: (a) Deontologically based rights theory; (b) Community based rights theory. A universal right to healthcare. Michael Boylan. International Journal of Politics and Ethics 1.3 (Fall 2001): p197(16).

Moral Viewpoints • Deontologically Based Rights Theory (Does not depend exclusively on the consequences of an action to determine its morality) • There are a number of versions of deontologically based rights theory. Many follow from a natural rights tradition. What concerns us here is a form of the theory that states that there is some characteristic that all people possess that justifies their claim to that good as a right. This good is thus claimed solely on the basis of the claimant's status as a human being (or in some cases an "adult" human being). • There are several persuasive writers in the natural rights tradition that, at least, began with John Locke (if not earlier). The principle problem with this tradition is being able to ground a theory of rights upon some intersubjective principles. Following Kant, Alan Gewirth, Alan Donagan and others have tried to ground a deontological theory based upon the grounds of human action as per the following argument. A universal right to healthcare. Michael Boylan. International Journal of Politics and Ethics 1.3 (Fall 2001): p197(16).

Moral Viewpoints • Clearly, when our bodies are assailed by microbes (disease) or accident, we are subject to unwarranted bodily harm. Since the protection from such is a basic good of agency, there is a strong rights claim for the same against all members of the society subject to the "ought implies can" caveat. • In most cases, behavioral life-styles are either entered into consciously or via an opaque context. In the case of conscious choices, it would be my contention that most who choose a deleterious behavior do so out of ignorance. For example, many in the United States engage in exercise. It is presented as a healthy lifestyle. …that sports and exercise have combined to lead to a substantial increase in his practice over the years. Most of these patients thought they were engaging in something healthy, but it turned out to be otherwise. By intention these individuals believed that they were engaging in healthy behavior. There was good scientific evidence to support this belief. However, in fact, they were planting the seeds of their own injury. They were ignorant of the actual state of affairs. This is a classic case of ignorance mitigating culpability. A universal right to healthcare. Michael Boylan. International Journal of Politics and Ethics 1.3 (Fall 2001): p197(16).

Moral Viewpoints • The second category concerns opaque contexts. (10) In this case, the agent does not understand that what she is doing is actually hurting her. This is because she does not properly make inter-substitutable connections. For example if Jane drinks whiskey, she knows (a) that whiskey gives her pleasure and (b) that whiskey will kill her liver. However, when Jane considers drinking she does not say to herself, "I will now drink whiskey in order to kill my liver." This is because the context is opaque. lane does not make the requisite substitution, and thus only sees the proposition, "I will now drink whiskey in order to receive pleasure." Since an opaque context is another instance of ignorance, it is my contention that it, also, is not fully culpable. Because of this, medical personnel should feel secure in fulfilling their professional obligation of beneficence without regard to the behavior of their patient. A universal right to healthcare. Michael Boylan. International Journal of Politics and Ethics 1.3 (Fall 2001): p197(16).

Moral Viewpoints • Support for Right • The Argument for the Moral Status of Basic Goods • Everyone has at least a moral right to the Basic Goods of Agency and others in the society have a duty to provide those goods to all • Basic Goods • Level One: Most Deeply Embedded (7) (that which is absolutely necessary for human action): Food, clothing, shelter, protection from unwarranted bodily harm • Level Two: Deeply Embedded (that which is necessary for effective basic action within any given society): • Thus, from the point of view of the above deontological theory, all people have a claims-right to level-one basic goods of agency. This is not an endorsement of medical procedures that concern secondary goods (such as cosmetic surgery). First, we have to address the claims of level-one basic goods. A universal right to healthcare. Michael Boylan. International Journal of Politics and Ethics 1.3 (Fall 2001): p197(16).

Moral Viewpoints • Community Based Rights Theory • Community rights theories may have their origin in Hegel and have been recently advanced by Michael Sandel. (12) • Justice for the Singer-style communitarian must show that it is in the community's interest that a universal right to health care be established. This could be done in a homogeneous community via ethical intuitionism. Everyone simply immediately grasps the justification for a right to health care. More popular for communitarians is an appeal to virtue ethics. • In this argument one might appeal to the virtue of benevolence (for example) and the shared commitment to the consequences that benevolence would entail for community health care. A universal right to healthcare. Michael Boylan. International Journal of Politics and Ethics 1.3 (Fall 2001): p197(16).

Moral Viewpoints • This idea of correlative rights is derived from Wesley N. Hohfeld, Fundamental Legal Conceptions (New Haven Conn.: Yale University Press, 1919). • In that work Hohfeld describes a "claims right." A claim is a right with a specific correlative duty of the form "x has a right to y against z in virtue of p." • In this way, rights and duties are correlative. A right of one agent is identified as the duty of some other agent. A right is a duty seen from another standpoint. A universal right to healthcare. Michael Boylan. International Journal of Politics and Ethics 1.3 (Fall 2001): p197(16).

Moral Viewpoints • Objectivism • Based on pure capitalism. • Does not consider healthcare to be a right. • Way beyond lifestyle choices being a factor. • "[G]overnment intervention in medicine is immoral in principle and . . . disastrous in practice. No man . . . has a right to medical care; if he cannot pay for what he needs, then he must depend on voluntary charity. Government financing of medical expenses . . . even if it is for only a fraction of the population, necessarily means eventual enslavement of the doctors and, as a result, a profound deterioration in the quality of medical care for everyone, including the aged and the poor." -Leonard Peikoff, "Medicine: The Death of a Profession," Voice of Reason • “Under the system of socialized medicine in Canada and Europe, people die because waiting lists to see doctors are too long to permit them to receive cardiac care in time to save their lives. In Canada, for example, a patient typically must wait 24 days for an appointment with a cardiologist--and 15 additional days for the type of emergency bypass surgery that saved Bill Clinton's life.” -Andrew Bernstein • The moral belief in the right to health care beyond what an individual can afford--health care at other people's expense--leads inevitably to demand for unnecessary or superficial care that clogs doctors' offices, overfills hospitals and tasks the health care system beyond its capacities. The predictable result is the endless waiting lists of socialized medicine. • Comments • This may be a realistic view of a true poor socialized healthcare system. • Objectivism does not offer a pragmatic solution for our country. www.aynrand.org

Moral Viewpoints • Objectivism "Universal" Health Care Is ImmoralWednesday, September 13, 2006 Irvine, CA--"Governor Schwarzenegger should be commended for his commitment to veto the California Health Reliability Act, which seeks to eliminate private medical insurance and establish a state-run health insurance system in California," said Yaron Brook, executive director of the Ayn Rand Institute. "But the basic issue is not, as the governor indicated, that the system would be too expensive. 'Universal' health care is immoral. "Health care is not a right. The fact that someone cannot afford the latest medical test or treatment does not entitle him to force others to pay for it--just as he is not entitled to a free gym membership on the grounds it would improve his health. "There is a crisis in health care, but its cause is government interference in the health care system. The solution is to leave doctors, patients and insurance companies free to deal with each other on whatever terms they choose--not to socialize American medicine." • Comments • This does bring up the question of other services we might consider ourselves entitled to if we consider healthcare as a right. • This raises the issue of how safe our country would be if the government played no role at all in healthcare. www.aynrand.org

Obstacles to Moral Action • "the major issues about right to health and health care turn on the justifiability of social expenditures rather than on some notion of natural, inalienable, or preexisting rights."

Obstacles to Moral Action • Ethics can't not play a role, because ethics concerns whatever is the most important in the way that human beings treat each other. And so since health is a very important part of human life, we can't not have ethics in health care. I guess the other ingredient, is that our resources for it are limited. And it's not just that the resources are limited, it's that the obligations of citizens to help one another are not infinite. We saw in the collapse of the Soviet Union and the East Bloc that the idea of a society based on coerced altruism doesn't last. We certainly have got to have some altruism in this society, and we have obligations to help our fellow citizens, but they aren't unlimited. There's a certain point at which I get to keep a certain amount of what I have earned and worked for.

Obstacles to Moral Action • The second thing I think we need to do is to learn that we have to say no. We have got to be willing to say no to identified individuals and make it stick. We have to say no in very careful ways and have very good reasons for saying no, but if we're going to draw limits, we have to actually enforce them. And that means enforcing them when it affects a real person who's right here in front of us and who would benefit if we made an exception. E. Haavi Morreim, PhD, Professor, Dept. of Human Values and Ethics College of Medicine University of Tennessee

Obstacles to Moral Action • "All other things being equal." That has to be the most ironic statement ever. It never occurs in real life.Who should get treatment first: the smoker or the non-smoker? Oops, I forgot to tell you, the smoker is 25, the non-smoker is 60. Oh, did I mention that the smoker is a factory worker and the non-smoker is a Nobelist? One more thing: the smoker is a widely-loved father of 7, the non-smoker is an neo-Nazi whose only daughter wishes him dead.Since "all other things" are never equal, one is forced to assign points to various traits. How does one assign relative weights? One person might not take care of himself properly because he spends all his time taking care of others. Another might be a poster-boy for health and fitness regimens, because he is a self-absorbed narcissist. Do we really want to reward the latter?I would guess that few people are so far to one end of the spectrum that the choice is a no-brainer. The vast majority will be somewhere in the middle, with good health habits and bad, good personal qualities and bad, good social qualities and bad. Judging fairly among the vast majority would require omniscience, and discriminating against the very few "obvious losers" would have little effect.

Conclusion • Based on the ethical considerations we believe that “Healthcare”, constituting treatment, is a “right” of all individuals. “Lifestyle” which is very subjective and not well defined cannot be considered capable of preventing the duty and obligation of healthcare provider to the patient. Healthcare cannot be ethically withheld from patients based on “Poor Lifestyle”.

Probable Reality • The increased costs of healthcare will through the very nature of supply and demand will limit the available resources capable of providing healthcare. General triage methods will reduce the level of care given to patients that have created a chronic condition from their “Poor Lifestyle” whether factual or perceived.

Should medical care be withheld from those individuals that have made "poor lifestyle choices"? (Managed Care)