In Brody and Englehardt’s article “Access to Health Care” the authors discuss various healthcare systems. They conclude the article with many questions concerning the justice of healthcare, as well as the validity and practicality of implementing a universal healthcare system. These questions present a number of valid concerns, including Singer’s question of whether a health care system must have only one tier in order to provide acceptable healthcare to the poorest members of society. The culmination of these questions seems to be the relationship between social equity and individual rights.

While these questions are valid, Brody and Englehardt make a singularly important point early on in their article: since the nineteenth century, societies have made an effort to provide those who could not afford healthcare with the bare minimum, even if this were for the sake of society as a whole and not out of care for the individuals most at risk. In the early nineteenth century, this meant providing basic public health measures such as proper sewage disposal. In nineteenth-century Germany, basic health care coverage included “third class” care. In twentieth-century Britain, it included enrollment under a general practitioner for 95% of the population.

There are many messages to glean from this article, and many questions are raised. However, what stands out to me is that societies supposedly far less evolved than ours managed to provide the minimum standards of healthcare to upwards of 90% of their populations. Why does it seem like this is such a hard goal to accomplish in the US today?

It seems to me like the question Singer raises is not yet applicable to healthcare in the United States. Before we debate the merits of social equity versus individual rights, we must make sure that everybody has the bare minimum. Until then, whose rights according to the free market are being denied is a moot point.

When I was reading the questions at the end of the article, my mind wandered to every American’s right to counsel under the constitution. When a US citizen is accused of a crime, he is guaranteed the right to a legal representative. The quality of this representative is not ensured. He may hire a different one if he so chooses and can afford to. While this does not provide the perfect analogy for healthcare, which is arguably more important and much more fickle, it seems to me that at least these general guidelines should be in place for healthcare provision in America. Other people may have better healthcare than you. If you have enough money, you may have different or better options than those of a lower economic standing. But you will always have the right to a doctor.

Perhaps this seems idealistic or simplistic in light of the questions which Brody and Englehardt raise. However, I would argue that a change in the US healthcare system needs to start somewhere, and that providing every patient with a doctor is a logical place to start.

References

O’Neill (2004) takes on a somewhat utilitarian view of informed consent in light of public health issues, essentially arguing that when public health provisions are for the benefit of the greater good they should be compulsory:

“It has come to seem controversial on the basis of an illusory assumption that all medical provision, and with it public health provision, can be organized on the basis of informed consent of individuals. It cannot” (1136).

This is a reasonable proposition. It seems that if an action is necessary on the part of individuals in order to protect the population at large, it should indeed be considered the correct course of action for each individual to take, regardless of their personal beliefs or convictions. Take for example vaccinations. When parents fail to vaccinate a child, they put that child (and her peers) at risk for the unnecessary contraction of a disease. If all children in a community are vaccinated, the community at large is safer, healthier.

However, O’Neill devalues informed consent to too great a degree in his claim that “an adequate ethics of public health needs to set aside debates about informed consent and to consider the permissible units of just compulsion for various types of public good.” For while informed consent does indeed deal with the autonomy of individuals, O’Neill disregards a significant portion of the concept — the “informed” part of “informed consent.” Informed consent  (in most cases) doesn’t necessarily mean that an individual is irrevocably free to say yes or no to a procedure regardless of consequence; rather, it represents an individual’s right to be educated about a procedure they are going to undergo or a medicine they are prescribed. In the case of public health, this aspect of informed consent is no less important than it would be on an individual basis.

In this way, compulsory actions taken in the name of public health should still be under the scrutiny of bioethical debate. While it may hypothetically be ethical to make some action compulsory in the name of public health, the manner in which this is done is still important. In the case of the vaccination example, explaining to parents clearly and concisely why their children should be vaccinated, whether this be at the doctor’s office face to face or in the form of a pamphlet or television program, is a way of respecting the autonomous nature of the individuals at large — the parents and their child — while still acting in the name of the greater good.

In her article, O’Neill makes compulsion seem much more cut-and-dry than it truly could ever be. A mass public health movement meant to benefit an entire population still affects the lives of individuals. Accordingly, the needs and wants of the individuals cannot be completely ignored and their concerns must be answered, whether or not they are given their way in the long run. O’Neill confuses the right of informed consent with complete unhindered freedom and therefore misconstrues the details of what a compulsory public health initiative would truly entail.

O’Neill, Onora. “Informed consent and public health.” Philosophical Transactions of the Royal Society of London. Series B: Biological Sciences359.1447 (2004): 1133-1136.

Genetic engineering is undoubtedly a sticky subject, one which raises immediate images of designer children, ultra-athletes or scholars handpicked by their parents to be the best. Most often when we discuss the bioethical nature of genetic engineering, we think of a child’s sex, eye color, height, intelligence. However, we must not forget that a person’s physicality is not the only thing determined by their DNA; many of our behavioral tendencies root from the depths of our genetics as well.

Here is where the question of genetic engineering becomes even trickier to answer: what if we could control for morality in our children? What if human offspring were kinder, more empathetic and compassionate, not because of any lesson taught to them by their parent, but because of a pre-selected genotype predisposing them to these desired qualities? Would this be permissible, or perhaps even obligatory, in modern society?

Faust suggests that as there is a genetic basis to most, if not all, complex human behaviors, especially personality. While environment also has something to say in the development of a child, there is no escaping DNA. With this in mind, she suggests that eventually, it might be possible for couples to select a haplotype predisposing their child to moral behavior: a MoralKinder haplotype (MK+). While this would not guarantee moral behavior in all situations, there would be an increased and statistically significant chance that the child would behave better in most.

Sandel cites many problems with genetic engineering and cloning: lack of autonomy for the individual whose genes are being altered, commodification of human traits, the threat of discrimination in society. It seems, though, that most of these arguments apply to physical genetic engineering. Could we call it dehumanizing if we selected for a haplotype which would increase our children’s humanity? Would the moral problems associated with physical genetic engineering not be at least partially dissolved if genetic moral enhancement were implemented?

Perhaps this issue is not as clear-cut as it seems, though. For some, this seeming increase of humanity appears as a threat to free will and human nature. Sandel points out that what we see as perfecting human nature “threatens to banish our appreciation of life as a gift, and to leave us with nothing to affirm or behold outside our own will” (103). Thus the possibility remains that by attempting to whittle down one end of the behavioral spectrum, humans are narrowing down their natural capacities as opposed to becoming the “masters of nature” (Sandel 103). Additionally, some argue that adding ease to the process of learning morality may devalue it.

However, Faust argues that selecting for MK+ would improve societal morality on the whole and would not remove the free will of the child. A child with a high moral capacity is like a child with a high intelligence quotient; she is not forced to make a certain, arguably better choice, but will certainly be more likely to. And again, a higher IQ does not devalue mathematical or literary abilities in our society; on the contrary, these gifts are praised.

While genetic moral enhancement is still both controversial and fully hypothetical, it provides interesting insight into the direction which genetic engineering might move. Perhaps we can use such an example to look at the ways in which the science of genetic engineering could improve our society, and use this to consider the morality of this issue.

Works Cited

Sandel, Michael J. “The Case Against Perfection: What’s Wrong with Designer Children, Bionic Athletes, and Genetic Engineering.” Arguing About Bioethics. Ed. Stephen Holland. London:   Routledge, 2012. 93-104. Print.

Faust, Halley S. “Should We Select for Genetic Moral Enhancement? A Thought Experiment Using the MoralKinder (MK+) Haplotype – Springer.” Should We Select for Genetic Moral Enhancement? A Thought Experiment Using the MoralKinder (MK+) Haplotype. Springer Science, 01 Dec. 2008. Web. 04 Feb. 2014.