Week 15 Lecture/Reading Notes (Philosophy 341)
Week 15 Lecture/Reading Notes (Philosophy 341) Classics 320
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This 7 page Class Notes was uploaded by Hannah James on Thursday December 10, 2015. The Class Notes belongs to Classics 320 at a university taught by Laura McClure in Fall 2015. Since its upload, it has received 16 views.
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Date Created: 12/10/15
Week Fifteen Readings Comparison: US to Canada Longer life expectancy, less infant mortality Everyone is fully insured without copayments or user fees o Not “socialized medicine,” public coverage for private delivery US citizens less likely to have regular medical doctor, and twice as likely to forgo needed medicines Wait times roughly 50% longer in Canada (vary hugely place to place) Medical professionals paid much more in US Drugs 40% cheaper (20% vs 40% don’t fill prescriptions because of cost) Technology more in US, but used more extensively in Canada Malpractice litigation: payouts higher in Canada, but lawsuits less common Wilkinson and Marmot: “Social Determinants of Health” The Social Gradient o Life expectancy is shorter and diseases are more common further down the social ladder of each society People lower run at least twice the risk of serious illness and premature death o These differences have both material and psychosocial causes Stressful economic and social circumstances cause physiological wear and tear on their health o Life contains a serious of critical transitions (childhood, primary to secondary educations, leaving work and starting a family, etc.) Each of these changes affect health by pushing a person down a more or less advantaged path o Good health involves reducing levels of educational failure, reducing unemployment/insecurity, and improving housing standards Stress o Stressful circumstances are damaging to health and may lead to premature death o Stress problems are more common in lower income brackets o Stress stimulates hormones and other responses, which affect the cardiovascular and the immune systems o Policy should reduce major causes of chronic stress (should support young families, encourage community activity, reduce financial insecurity, etc.) Early Life o The impact of early life and education lasts a lifetime o Slow growth and lack of emotional support raise the lifetime risk of poor physical health and reduce cognitive and emotional functioning in adulthood o Poor circumstances in pregnancy leads to less than optimal fetal development, causing health risks o Risks should be reduced through improved preventative health care and improvements in education Social Exclusion o By causing hardship and resentment, discrimination affects health o Social exclusion results from poverty, racism, discrimination, unemployment, etc. Prevent people from participating in education, services, citizenship activities, etc. o To reduce the effects of exclusion, all citizens should be guaranteed minimum income, there should be intervention to reduce poverty, legislation should prevent discrimination, etc. Unemployment o Job security increases wellbeing; unemployment causes more illness and premature death Job anxiety increases effects on mental health (stress, depression, etc.) o Policies should prevent unemployment/job insecurity, reduce the hardship of the unemployed, and restore people to secure jobs Social Support o Friendship and good social relations improve health dramatically Give people the emotional and practical resources they need o Belonging to a social network makes people feel cared for, loved, and valued o Social cohesion (the quality of social relationships and the existence of trust and respect in communities or in a wider society) helps protect people’s health o Policies should reduce social and economic inequalities as well as social exclusion (more social cohesion; better standards of health) They should also improve the social environment in schools, work, community, etc. Addiction o Use of substances is influenced by wider social setting o Use of alcohol, drugs, tobacco, etc. allow a release from reality, but they intensify the factors that made the person turn to substance in the first place o Policies should regulate availability through policies and licensing, and should inform people of their harmful effects Food o Global market forces control the food supply, so healthy food is a political issue o Access to gold, affordable food makes a big difference in people’s health o Poor people tend to have cheaper, processed food as a source of nutrients (people on low incomes are least able to eat well) o Policies should provide healthy, affordable food for all Deaton: What does empirical evidence tell us about the injustice of health inequalities? The birth of the gradient o Some people assume that the gradient showing that life expectancy and health increase with wealth has always been present, but data shows this to be false (used to not make a difference) This changed because innovations to better health were expensive, and thus only the wealthy could use them o This fact shows us that wealth and power themselves are useless against mortality (without the tools attained with them) This wealth difference isn’t the only factor that impacts health, but it is an important one Men and women o Men die more often than women (high mortality rate), but women get sick more often than men (higher morbidity rate) Children, race, and health care o Children have worse health outcomes when their parents have less income or less education (similar at childbirth; get worse with age) These are examples of unjust inequalities that should be fixed o Racial inequalities is the second example of injustice Minorities have lower life expectancy, more chronic diseases, etc. It is thought that the stress of living daily in a racist society causes these poor health outcomes It is also possible that minorities receive worse health care because the hospitals and clinics that serve them are lower quality Minorities are also more likely to live near environmental hazards (toxins, pollutants, etc.) often to live in cheaper housing areas Socioeconomic status, education, income, and health o There is a consistent link between civil service rank (measured by income) and a wide range of health outcomes Thus, high ranks promote health and low ranks endanger it o To correct injustices, policies should focus on early childhood health, nutrition/disease prevention, and trying to moderate the effects or parental deprivation on child outcomes (lower income/education parents generate kids with more health risks) Unhealthy behavior by the poor o Poor people are more likely to smoke or be obese than rich people They are also less likely to exercise regularly, more likely to live in polluted areas or drink alcohol, etc. o The adverse circumstances of poor people lead to these decisions, and thus these “choices” are often hard to avoid for poor people International health inequalities o Differences in life expectancy between countries are much larger than differences in life expectancy within countries Infant mortality rates are the main drivers in these differences o People in impoverished countries are dying of things that are easily treated, prevented, or cured (polio, malnutrition, diarrhea, etc.) That’s why these differences are perhaps the most unjust differences involving health o Differences in income are also much larger between countries o There is debate over whether the inequalities between countries are either just or unjust (is justice a matter of people within a country through their social contract?) But there is a consensus that countries should have at least minimally decent health for everyone But the contributions to poor countries by rich ones can undermine the creation of a society that can allow these changes longterm (so fixing these inequalities is difficult) Income inequality as a risk factor for health o Inequality and its effect on health is profound, especially through politics Political inequality leads to health inequality o The rich have no need for disability, national health care, etc., and thus do not want to pay taxes to support them They have huge political influence to prevent the creation of such plans Daniels: Justice, Health, and Healthcare Three questions of Justice o Is healthcare special? It is special because of its impact on opportunity (maintains normal functioning) Thus, it is morally important to protect normal functions (they contribute to protecting opportunity) The relationship between healthcare and opportunity shows the appropriate principle of distributive justice for healthcare protects equality of opportunity Any theory of justice that supports a principle assuring equal could thus be extended to healthcare This theory has several implications for the design of our healthcare institutions and for issues of resource allocation It supports the provision of universal access to appropriate healthcare—including traditional public health and preventive measures o Could be through public or mixed public and private insurance schemes Healthcare aimed at protecting fair equality of opportunity should not be distributed according to ability to pay, and the burden of payment should not fall disproportionately on the ill o When are health inequalities unjust? There are social determinants of health Much contemporary discussion about reducing health inequalities by increasing access to medical care misses this point, for many factors before medical care is needed affect health (should reduce those as well) By establishing equal liberties, robustly equal opportunity, a fair distribution of resources—the basics of Rawlsian justice—we would go a long way toward eliminating the most important injustices in health outcomes Observations show that the health of nations depends, in part, on factors other than wealth Culture, social organization, and government policies also help determine population health o Variations in these factors may explain many of the differences in health outcomes among nations One especially important factor in explaining the health of a society is the distribution of income “The health of a population depends not just on the size of the economic pie, but also on how the pie is shared” Numerous studies support this relativeincome hypothesis, which states, more precisely, that inequality is strongly associated with population mortality and life expectancy across nations o Rich countries vary in life expectancy, and that variation dovetails with income distribution o In particular, wealthier countries with more equal income distributions have higher life expectancies than the United States, despite having lower per capita GDP Same differences are seen between states Differential investment in human capital—in particular, education—is a strong predictor of health (literacy, etc.) o How to meet competing healthcare needs fairly under reasonable constraints? Answering these questions would be easier if people could agree on principles of distributive justice that would determine how to set fair limits to healthcare If societies agreed on such principles, people could simply check social decisions and practices against the principles to see if they conformed o But people do not agree Under what conditions should we accept as legitimate the moral authority of those making rationing decisions? (“I shall develop the following argument”) 1. We have no consensus on principled solutions to morally controversial problems, and general principles of justice for healthcare fail to give specific guidance about how to solve them 2. In the absence of such a consensus, we should rely on a fair process for arriving at solutions to these problems 3. A fair process that addresses issues of legitimacy will have to meet several constraints that I shall refer to as “accountability for reasonableness” o These constraints tie the process to deliberative democratic procedures o This issue of legitimacy and fair process arises in both public and mixed publicprivate healthcare systems and it must be addressed in countries at all levels of development We would take a giant step toward solving the problems of legitimacy and fairness that face public agencies and private health plans making limit setting decisions if the following four conditions were satisfied Publicity Condition: Decisions regarding coverage for new technologies (and other limitsetting decisions)must be publicly accessible Relevance Condition: The rationales for coverage decisions should provide answers to how the society would provide “value for money” in meeting the health needs of the population under resource constraints o Answer will be “reasonable” if it appeals to principles that are accepted by people who find terms of cooperation that are mutually justifiable Appeals Condition: There is a mechanism for challenge and dispute resolution regarding limitsetting decisions, including the opportunity for revising decisions in light of further evidence or arguments Enforcement Condition: There is either voluntary or public regulation of the process to ensure that conditions 1–3 are met Conclusions o **This argument is basically an extension of Rawls’ Theory of Justice** o Three ways that the theory supports Daniels’ answer to the third question First, we use a fair process to arrive at what is fair, since we lack prior consensus on the relevant distributive principles This retreat to procedural justice is at the heart of Rawls’s version of a social contract Second, Rawls places great emphasis on the importance of publicity as a constraint on theories of justice Principles of justice and the grounds for them must be publicly acknowledged o This constraint is central to the conditions that establish accountability for reasonableness Finally, Rawls develops the view that “public reason” must constrain the content of decisions about fundamental matters of justice, avoiding special considerations that might involve comprehensive moral views that people hold o In pointing out these connections, I am not suggesting that this is the only approach to developing a theory of justice that applies to all aspects of health and healthcare Indeed, I have pointed to other theories that converge in practice and to some extent in theory with the approach adopted here o I am proposing that concerns about justice and fairness in health policy should look to political philosophy for guidance and that some specific guidance is forthcoming At the very same time, seeing how we have to refine work in political philosophy if it is to apply to real issues in the world, we should abandon the unidirectional implications of the term “applied ethics” or “applied political philosophy”