All posts by Sandip Patel

Why Access to Healthcare is Necessary for Equality of Opportunity

In his article, Health Care and Equality of Opportunity, Gopal Sreenivasan argues that universal healthcare isn’t really the answer to our call for equality of opportunity. Yes, a loss of health can take away one’s fair share of opportunity, but health is not the same as healthcare. There are social determinants  to health that  make a much bigger impact on health than any healthcare system. These social determinants boil down to income levels. Poorer people suffer from more chronic conditions and have on average, lower life expectancies. That’s not surprising. But Sreenivasan wants to make it clear that having access to a doctor and a clinic won’t change that. It’s poverty that influences key factors to health like diet, living conditions, health literacy, and education. Without addressing this poverty – and since equal opportunity is based on relative shares, reducing the income disparity as a whole, we will be doing little in the long run.

It seems that Sreenivasan has overlooked the fact that providing universal access to healthcare is a crucial step to centering the social gradient in the same way that a system like public education is. Imagine living in a country where access to public education was as limited to lower-income families as healthcare is today in the US. Sreenivasan could plausibly make the same logical argument. There are other social determinants that determine educational and career success. Addressing income inequality is the real solution, one might argue. The false assumption being made here is that these systems do little or nothing to change the social gradient itself.

Healthcare can be extremely expensive, and it pushes people into poverty. Poverty rates rise considerably when healthcare costs are taken into account. In fact, covering healthcare costs for the poor has the potential to make the biggest difference according to census data. The current measure of how many people are officially living in poverty does not take medical costs into account. If out-of-pocket healthcare costs were included, 10 million more people (a 3.3 point increase in the poverty rate) would be added to our count.


S. R. Collins, New Census Poverty Measure Shows Medical Expenses Push 10 Million More Americans into Poverty, The Commonwealth Fund Blog, November 2011.

Sreenivasan, Gopal. “Health care and equality of opportunity.” Hastings Center Report 37.2 (2007): 21-31.

Mandatory Vaccination Policies

Utilitarian calculations guide public health as a rational effort to maximize the net wellbeing of the population. Utilitarian measures promise effectiveness, action, and widespread applicability. However, in our society, even the most promising or rational utilitarian measures will be blasted as soon as it endangers  the core American value of individual liberty.

The Model State Emergency Health Powers Act (MSEHPA) for example, was blasted as an attack on individual freedoms by many critics. MSEHPA was a proposal meant to help state governments reform outdated and inadequate public health policies and infrastructure after 2001. It proposed giving states the legal right to ignore certain individual liberties in emergency situations in the interest of public safety. This included permitting public health authorities to physically examine, test, vaccinate, treat, and quarantine individuals as necessary “to prevent or limit the transmission of a contagious disease.” Additionally, authorities would have the right to destroy any facilities or property that posed a public health threat due to contamination. 

Lawrence Gostin, a leading author of the MSEHPA proposal, responded by stating that “in a country so tied to rights rhetoric on both sides of the political spectrum, any proposal that has the appearance of strengthening governmental authority was bound to travel in tumultuous political waters.”

The MSEHPA does propose a breech of personal liberties, and these powers are supposed to  be reserved for emergency situations only. But there’s still no denying that it is a part of a post-9/11 reaction that has gained security at the cost of individual freedoms. The consequences of this reaction are only beginning to resurface as we examine the NSA’s abuse of the Patriot Act. Americans have witnessed how easily power can be abused by the bureaucrats we have entrusted.

Governmental mandates and heightened legal power will always come with a backlash.  What does this mean for public health, and vaccinations in particular? That a mandatory vaccination policy would  be extremely controversial – even to those who believe that it’s the right thing to do. Forget vaccinations. We could be talking about some magical miracle potion here. The fact remains that there’s something justly frightening to the American people about giving the government the power to inject substances into anyone and everyone. As someone who generally agrees that all adults and children should be vaccinated, I believe this direct conflict between utilitarian aims and individual liberty means that we have a duty to raise awareness and incentivize vaccinations without resorting to government mandates.


Gostin, L.O. “Public Health Law in an Age of Terrorism: Rethinking Individual Rights and Common Goods.” Arguing About Bioethics. London: Routledge, 2012. 374-384. Print.

Gostin, Lawrence O. “Model State Emergency Health Powers Act: Public Health and Civil Liberties in a Time of Terrorism, The.” Health Matrix 13 (2003): 3.


The Limits of Informed Consent

The autonomy of the patient has triumphed, in legal terms at least. Doctors and health care personnel are legally required to disclose information about treatments to patients, and patients have the legal right to say “yes” or “no” to any treatment. But how practical is informed consent? The legal implementation of informed consent seems to be mostly a matter of filling out extra paperwork. So that seems practical enough. On the other hand, actually practicing the moral values behind informed consent is much more difficult.

We value the freedom to choose on so many levels. We have a right to choose as consumers, as voters, as citizens and as competent people in general – so then why not as patients? Of course patients should have a right to consider multiple opinions, assess alternative treatments, and then make a choice on their own. But in reality, a patient’s autonomy is highly limited. A lot of the limiting factors are neither inconsequential nor easily avoidable. In Barriers to informed consent, Lidz et al. outline how patient trust, physician expertise, acute illnesses, and complex medical systems make true informed consent difficult to achieve.

Are we morally obligated to try to overcome these obstacles? Or can they be viewed as the practical, real-world limits to our abstract ideals of patient autonomy? This question isn’t really about obstacles like access to healthcare or the complexity of the healthcare system. There’s no question that we should be trying to increase access to care and streamlining the system. The interesting obstacles are those that deal with the doctor-patient relationship. Should we be trying to change this relationship on a moral basis?

Let’s consider patient trust and physician expertise – both important obstacles to informed consent. Patients often don’t really want to make a decision based on what they know about their medical condition. They instead trust the physician enough to make such decisions for them. I see this as a clear act of autonomy. It’s a very rational choice to trust a trained professional’s informed decision over one’s own, likely less-informed decision. Ah but that’s where physicians have to make sure patients are fully and objectively informed, right?  Well even if a physician explains the relevant diagnosis and treatment to the patient in an easily comprehendible way, most patients will not know the essential mechanisms and pathology behind the physician’s decision. They’ll instead be given a simplified picture of a complex system – one that is inevitably going to be biased towards the physician’s decision anyway. We can’t blame physicians for such simplified, biased explanations any more than we can blame scientists for being biased towards one particular theory or paradigm. In the words of Galileo, “it is not within the power of the practitioners of demonstrative sciences to change opinion at will,” (p 125). They are compelled to believe what they believe by the power of reason.

All of this is not to say that the “informed” part of informed consent is irrelevant just because it is likely to have a bias. But maybe the information is, for practical considerations, less important than what we call patient trust – a form of rational consent.


Galilei, Galileo, and Maurice A. Finocchiaro. The Essential Galileo. Indianapolis, IN: Hackett Pub., 2008. Print.

Charles W. Lidz, Ph.D., Alan Meisel, J.D., Marian Osterweis, Ph.D., Janice L. Holden, R.N., John H. Marx, Ph.D. and Mark R. Munetz, M.D. “Barriers to Informed Consent.” Arguing About Bioethics. Ed. Stephen Holland. London: Routledge, 2012. 93-104. Print.