This article challenges the claim that “access to [universal] health care is necessary to ensure health, which is necessary to provide equal opportunity” (Sreenivasan 21). The author doesn’t claim that universal healthcare or equal opportunity are unimportant, but rather that equal opportunity doesn’t necessarily result from universal healthcare access.

It is hard to deny that ensuring better health allows people to accomplish more, which could be seen as providing them with more opportunities. Furthermore, providing healthcare seems like a perfectly logical way of ensuring health. However, the author explains that the core of this argument relies on defining opportunity, and specifically what everyone’s equal share of opportunities is. This is where the argument falls apart; not everyone starts with the same share of opportunities. Rather, the shares of opportunity that can be maintained, restored, or increased with better healthcare are actually better defined as “relative shares” (23). Healthcare facilitates better health, which in turn facilitates a maintenance of opportunities, but those opportunities are not equal by nature.

The purpose of this argument is not to discredit any benefits of universal healthcare, but rather sets the author up to make the next argument: using the same amount of money to ensure more socioeconomic equality actually has a bigger benefit on health and overall opportunity than just spending it on healthcare.  In the author’s words, “A society does more to move its citizens toward their fair share of health when it devotes the equivalent of the health care budget to improving the social determinants of health than when it runs a national health care system. It follows that equal opportunity does not require universal access to health care” (27).

I appreciate the fact that the author is not completely discrediting the role of universal healthcare. Rather, it addresses only a small portion of the overall problems created by the current socioeconomic gradient. As the paper acknowledges, and as I have discussed and read about in health and sociology classes, socioeconomic status is one of the most important factors in determining health outcomes, including disease rates and mortality rates. The following is an example of expected lifespan at age 50 in the mid-1900s based on individuals’ income brackets. Income inequality has only increased since then.

While, in theory, it sounds nice to spend money on fixing the problem of income inequality, accomplishing that is extremely difficult. There is no easy way of distributing the money or identifying who needs it the most.

The immediate implementation of some of these ideas may not be possible, but it is still important to acknowledge the fundamental causes of uneven distribution of health and unequal access to opportunities. It’s also important to acknowledge the flaws in arguments for and against important issues like universal access to healthcare. This article also does a good job of exposing many of those flaws. It is imperative, however, to ensure that healthcare benefits don’t get cut just because the motives for universal healthcare or certain treatments are flawed—they still play an important and beneficial role.

Thaler and Sustein discuss the idea of “Libertarian Paternalism,” to describe when and why paternalism is justified and often entirely inescapable. They raise many good points about the prevalence of paternalism in nearly every decision we make, but they also make arguments based on low-stakes decisions that are, at least in my opinion, less sound.

One of the first major points the paper argues is that there are not actually any “viable alternatives to paternalism” because someone must make a choice whenever presented with a decision that involves others. This is logical enough because any decision that involves others, even when they naturally don’t have a choice or knowledge of the decision, could be seen as a mild form of paternalism. However, the authors on to argue that there are really only three options for decision making by an authority figure:

1. to make choices that are best for those effected (in this case best for the cafeteria customer)
2. to make a random choice
3. to consciously make a “malicious” decision that would hurt those effected (in this case make customers obese by arranging food a certain way).

While these are all alternatives, this is not a comprehensive list of options, intentions, and outcomes. For example, it is possible that the manager made a choice that she thinks is in her or the cafeteria customers’ best interest, or perhaps one that appears to be in the best interest of the customers, but actually has unexpected, adverse effects on them, her, or the cafeteria employees or revenue. Furthermore, decisions about the design and layout of a cafeteria are low-stakes compared to a treatment decision that is a life or death matter, or at a minimum can cause a patient unnecessary suffering and stress.

It is important that the authors value performing cost-benefit analyses of decisions at any level. The goal of the paternalism they aim to justify is to provide some choice, but to limit or entirely remove the possibility of poor choices being made. By nature, paternalism is “the intentional overriding of one person’s preferences or actions by another person…” (Beauchamp and Childress 215). This obviously means that autonomy is greatly compromised no matter what, and when this is the case, it’s imperative to be continually assessing the benefits and drawbacks of decisions and treatments.  But even with this constant monitoring of the situation, allowing some decisions while limiting autonomy is tricky to accomplish.

This article draws many conclusions about paternalism and its justification based on a very narrow scope of decisions: the fate of retirement money and a cafeteria’s arrangement. Because of this, both the authors and readers must be extremely careful about applying these arguments and principles to patient care. Most decisions are not as straightforward as how much money a retirement account will make based on a binary choice. Emotional harms are also important to consider; patients or customers likely do not have a strong emotional attachment to the layout of the cafeteria they’re eating in, but they will certainly have strong emotional responses to their treatment, pain, and violations of their autonomy. Paternalism is not clearly justified or unjustified, and the benefits consequences must always be carefully and continuously weighed.

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York: Oxford UP, 2001. Print

This case raises two issues:

1. Did the mother make a morally incorrect decision by not moving to the tertiary care hospital like her family doctor recommended, which would likely improve the outcome of the daughter once she was born?
2. Is it morally acceptable to withhold treatment from the baby when there’s a high chance that she won’t survive anyway, and even if she does that she will have severe mental disabilities?

In this case, the first issue can only be examined retrospectively. Many people might side with one of the residents who said that it was unfair to the baby that it had to suffer more because the mother didn’t take the doctor’s advice and go to the other hospital. While it likely would’ve been very beneficial for the mother to move to the tertiary care facility, I don’t think the mother purposefully harmed her baby. First of all, she was in a very vulnerable and uncertain state. She was unsure of when the birth would occur, and how it would go. She also suffered two other miscarriages in the past. Therefore it’s understandable that she wanted the support of her husband and her parents, which she could have by staying in the community hospital. It also appears that the her doctor failed to properly inform her about the importance of moving to the other care facility. He only mentioned it to her in a “brief conversation.” With regard to the information elements of the informed consent model, which includes “disclosure,” “recommendation,” and “understanding” (of the disclosure and recommendation of the plan), the doctor does not give adequate time to ensure that the mother fully understands the information (Beauchamp 124). If the doctor had a prolonged conversation where he discussed his concerns and the benefits of the tertiary care facility more thoroughly, then the mother would have been more likely to move to the other facility, but if she still hadn’t, then there would be more grounds to accuse her of purposeful wrongdoing.

Both the parents of the girl and the healthcare professionals are divided over the second issue. The mother wants to give the daughter every chance to live, the father is concerned about the daughter’s quality of life if she survives and the toll it will take on their marriage, the resident doesn’t think that living a severely cognitively impaired life would be worth it and describes how much it will cost the family to treat her later in life, and the pediatrician does not want to suspend treatment since she is not braindead, and is hopeful about the fact that the girl has a chance of surviving with little or no cognitive impairment. The father and resident seem to be most concerned with the resources, time, and money it will take to care for the girl. The pediatrician is clearly framing the possible outcomes by mentioning her chances of survival and life without disability, and hardly acknowledges the possibility of death or a severe mental disability. The mother is clearly emotionally attached to the daughter, especially since all of her other children died. While there is a degree of bias in everyone’s decision, I don’t think that suspending treatment is the right course of action, especially considering that the daughter might not die, and her condition would be even worse if she lived.

Citation:

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York: Oxford UP, 2013. Print.

The surgeon in this case is faced with legal and moral obligations to the woman and her family, and it is important to understand the law and the necessity of effectively measuring competence, regardless of how the surgeon feels about the woman’s decision.

From a strictly legal standpoint there is very little that the surgeon can do to force the woman to accept a surgery, even if he feels her decision to refuse care is medically or morally irrational. An example of a Supreme Court case that illustrates this point is Lane v. Candura in which a woman refused an amputation that would save her life. The woman’s daughter attempted to gain the rights of guardianship, and by extension right to force her mother to receive the amputation, but the court stated that the woman had the right to refuse treatment and was fully competent to do so. While the woman’s child in case 1.1 is not seeking full guardianship and control over his mother like the child in the Supreme Court case, and the specific reasons for refusing further treatment are somewhat different between the two cases, there is a strong parallel between these cases. In the Supreme Court decision, the woman was allowed to refuse the amputation surgery, and it seems that the woman in case study 1.1 has a similarly justifiable ability to refuse treatment.

Regardless of the law, it is a good idea for the surgeon to perform a comprehensive analysis of the woman’s competency in order to avoid oversight that might clear up a moral ambiguity or be necessary to protect himself in the event that the woman or her family sues him. Dr. Leo’s list of questions provided in his article titled “Competency and the Capacity to Make Treatment Decisions” provides a solid list of questions that can be used to determine a patient’s ability to understand the nature of the treatment in question and the results of their decision.

Based on the information presented in the case, the woman appears to be able to understand her treatment options and the severe likelihood of death if she chooses to forego any addition medical care.

With this in mind, the main cause for concern about the woman’s competency is ensuring that there aren’t any controlling factors, especially relating to the pain and frustration she is feeling, or potential animosity towards her family. The surgeon might want to ask about the woman’s pain levels, her relationship with other family members, and what she is most frustrated by. It might even be appropriate to ask some of these questions after the respirator has been removed since it can cause discomfort and frustration. It could also be helpful to attempt to regain the woman’s trust in surgeons by trying to connect with her at a more personal level.

If the woman remains adamant, especially if pain levels are low and she is not feeling pressured or upset by her family, then the surgeon does not have many options but to allow her to refuse treatment and possibly face an eventual suit from the son.

Citations:

Leo, Raphael J. “Competency and the Capacity to Make Treatment Decisions: A Primer for Primary Care Physicians.” The Primary Care Companion to The Journal of Clinical Psychiatry 01.05 (1999): 131-41. Web.