Showing posts with label Kant. Show all posts
Showing posts with label Kant. Show all posts

Saturday, April 2, 2011

On the Ethics of Arizona Medicaid Charging Smokers and the Obese an Extra Fee

0 comments Posted by Find Insurance Online at 4:35 AM

MSNBC reports that “Arizona's cash-strapped Medicaid program is considering adding a $50 tax on single patients who smoke, have diabetes or are overweight. Arizona Health Care Cost  Containment program spokeswoman Monica Coury says the tax is intended to push patients to take better care of themselves. Coury says the issue is getting at the cost of health care while trying to stretch dollars and get people to take better care. ‘If you're not going to manage those things and take some personal responsibility, and in turn that costs the state more money, then you need to have some skin in the game,’ Coury said. . . . ‘You need to be responsible for the fact that your smoking costs us more.’ . . . State Sen. Kyrsten Sinema of Phoenix says it isn't fair to charge diabetics $50. Sinema says the fee fines people who may have medical conditions beyond their control. . . . The changes are part of a major revamp of Arizona's Medicaid program to find funds to restore transplant coverage — eliminated amid much controversy [in the fall of 2010].”

Ethical Analysis:

Focusing here on the ethical dimension of the proposed changes, I lay aside here the worthy question of whether the proposed changes are the optimal way to restore transplant coverage, or, more generally, to make up the funding shortfall facing Arizona’s Medicaid program. Ethically speaking, Coury’s reference to personal responsibility clashes head-on with Sinema’s claim of the conditions being beyond the patients’ control. Responsibility presumes that the agent has control over that which he or she is to be responsible. It makes no sense, for example, to hold President Obama responsible for the weather (unless the federal government has a top-secret way of controlling and changing the weather over U.S. territory).

In terms of smoking, the question is perhaps whether a drug addict has control of his or her addiction. To be addicted, according to the World English Dictionary, is to be dependent on something. Meriam-Webster’s Medical Dictionary asserts that dependence in turn involves being “unduly subject to the influence of another.” The question is thus whether being “unduly subject to” implies or involves the loss of control as opposed to merely control being more difficult. The qualifier of “unduly” suggests being subject to something excessively, according to the World English Dictionary. This does not signify the loss of control. Therefore, ethically speaking, smokers can be held responsible for their addiction to nicotine even though it is very difficult for them to quit. That smokers have quit demonstrates that those who do not quit cannot fall back on the fallacy that they have no control over their addiction. So to the extent that the smokers cost others, it is ethical to charge smokers more.

With regard to diabetes and obesity, a distinction can be made in terms of control. Losing weight, if only from restricting the quantity (and types) of food ingested, is within a person’s interval of control unless the excess weight if due to a disease and cannot be lost without risking the loss of minimal nourishment and health. I suspect that this qualification is misapplied by overweight people who presume that their “condition” is a result of an illness when over-eating (as well as a refusal to exercise) is the actual cause. Such persons, doubtless the overwhelming majority of obese people, can be distinguished ethically from those whose excessive weight is caused by a disease and cannot be lost without risk to one’s health and perhaps even life.

Apart from the illness caveat, the argument that overweight people have no control over their excess weight is effectively countered by the success that people have had in losing weight. Prima facie, one can reduce one’s consumption even in the midst of a presumed overwhelming urge to eat more. Therefore, it is ethical to hold overweight people responsible for their weight, and thus to charge them more if they cost others more. Diabetics are a more complex case.

Regarding obesity and (the ensuing?) diabetes, it may be that once a patient has the disease, nothing she could do would cure her of the disease. Otherwise, the person’s failure to reduce his weight while diabetic would be a basis for holding the person responsible not only for remaining overweight, but also for suffering from worsening diabetes. Furthermore, if being overweight is necessary for the onset of the disease, the diabetic could be presumed to be responsible for having developed the disease, and thus properly charged more for having it treated. However, to the extent that overweight people do not necessarily become diabetic, it may not be reasonable to assume that an overweight person should have acted to avert what is a mere possibility. In terms of a diabetic’s choices, if losing weight lessens or eliminates the (chances of, or continuance of) the sickness and the diabetic does not lose weight, a diabetic could rightly be held responsible and thus properly charged for the extra cost borne by others.

A few nuances should be made transparent. First, if the charges are not merely to reimburse others for the increased cost, but also to manipulate the “offender” to change his or her ways, it can be asked whether such manipulation is itself ethical and effective. If a person believes that his addiction, eating habits, or disease is a “condition” rather than a result of his choice, then it is unlikely that he would suppose that having to pay more would have anything to do with even a potential change in his “condition.” In other words, a link in the chain of reasoning presumed in the manipulation would not exist for the person to be manipulated.  Moreover, manipulation itself may be unethical unless, as in Kant’s categorical imperative, the rational being to be manipulated is treated not merely as a means, but also as an end in herself. If the end includes the patient recovering, this criterion may well be satisfied in Arizona’s proposal. In such a case, the noxious smell of manipulation may still pass the smell test.

Second, throughout this analysis, I have been assuming that the additional charges can be afforded by the patients and/or their insurance companies. If a patient cannot afford the extra fee and still provide for necessities such as food, shelter and obviously health care, as well as incidentals, then a basic human rights factor intercedes and it could be quite unethical to impose the fine/fee. Relatedly, to the extent that Arizona’s proposal involves reducing the number of enrollees in Medicaid, the goal itself may be unethical from the standpoint of the human right to survival, or life.

Third, if smokers and obese people are to be held responsible for their choices in health-care policy, it would be unethical to be selective in leaving out other choices that have negative consequences in terms of health (and cost). Even so, consistency zealously pursued can put the government into all of our lives with the result being that we have lost our liberty. That is, we might ask ourselves whether there is not a slippery slope involved in opening up our various decisions to governmental overview and charges. The imposition itself could be regarded as unethical, especially in a free society. Yet being forced to pay for the egregious choices made by others, such as by smokers and obese people, can also be regarded as involving an unethical transfer of responsibility. Accordingly, it is well and good, ethically speaking, that a society makes judgment calls respecting how far “egregious” extends. Being a matter of judgment and balance, there is no pre-established line in the sand to be sought in making this determination.

In conclusion, my ethical analysis supports the proposition that smokers and overweight people can be held accountable for their smoking and obesity, respectively, and perhaps even for being diabetic to the extent that mitigating the illness is within the patient’s previous or, more strongly, current control. This conclusion is of course beset by conditions. However, they do not deprive my conclusion of its main thrust—namely, that society has an ethical basis, and thus a right, to hold smokers and overweight people responsible for their inherently unhealthy choices by imposing an extra fee for government-supported health-care. To treat either smokers or the obese as somehow simply affected by, rather than as the agents of, their smoking or obesity is to engage in the subterfuge of an ideological agenda in the guise of science. Such a cloak is of course highly unethical.

Click to add a question or comment on the ethics of Arizona public health-care charing patients extra for smoking and obesity.

Source: http://www.msnbc.msn.com/id/42379077/ns/health-health_care/




 

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Saturday, February 26, 2011

Online Privacy and Advertising Databanks: Kant, Societal Norms, and Regulation

0 comments Posted by Find Insurance Online at 4:31 AM

$26 billion-a-year by 2011, the internet advertising market is lucrative to venture capitalists who want to invest into companies that help target online advertising. Between 2007 and 2010, venture firms invested $4.7 billion in 356 online-ad firms. "Its a huge market and it's growing," Chris Fralic at First Round Capital says. Fralic's company has backed 33Across, which analyzes users' social networks, and Demdex, which has a "behavioral bank" of user profiles. Ethically, user on-line privacy is at issue. I contend that user privacy can be protected from dangers of concern to users while willing users can benefit as consumers from information regarding products that they want and would not otherwise know of.

According to The Wall Street Journal's "What They Know" report, the top fifty American websites installed thousands of "cookies" and other tracking technologies on people's computers in 2010. The purpose was to create sophisicated dossiers on people's personal activities and to track them in real time. At the end of 2010, the U.S. Federal Trade Commission urged the creation of a "do-not-track" system and the Obama administration backed an online "privacy bill of rights." At the same time, the EU and its states were grappling with the same issue.  One issue there was whether a user simply turning on his or her computer and going online constituted consent to "cookies."  The relative lobbying power of the industry with the vested interest could be seen to differ between states (e.g., Britain and France).  In other words, governmental restrictions can not necessarily be counted on to protect privacy and thus obviate the ethical problem. Accordingly, I now turn to an ethical analysis, putting the question of government regulation aside.

As of 2011, Americans spend 28% of our media time online. Also, online-ad start-ups do not require a lot of money relative to start-ups in other industries. Many of the online ad start-ups attracting funding connect website operators with advertisers who want to capitalize, according to The Wall Street Journal, "on the Web's ability to target individual users." According to Nick Sturiale at Jafco Ventures, "Advertisers want to buy individuals." We are bought, in other words, by being targeted even in our social networking. In short, in going to where people are, there is a lot of money to be made by bringing ads to the people most likely to buy from them. To be sure, consumers benefit when they are made aware of products of particular benefit to them. In business terms, connecting people with products they want is like water going downstream: money is naturally to be made, so it will.  Hence even government-constructed channels or dams are apt to be subtly worked around as money-seekers inevitably seek out sources in more efficient ways. The ethics of privacy do not translate except if there is a financial backlash from actual or potential consumers spurring the ads (i.e., voting for privacy with their wallets and purses). I suspect that few users will spur online ads, however. First of all, consumers who would like to buy a new product tailored to their interests may not all object to the loss of their privacy. Enabling users to allow or disable cookies would allow consumers to make this decision. Secondly, users may not object because the fact that they have been researched and targeted is not typically transparent to them when no one uses the information against them in particular. The loss of privacy is abstract where one has no knowledge of it happening in real time and one does not feel harmed. Indeed, where such breaches are widespread, the use of the data uncovered is routinized and contained.  For example, if a given user's search of porn sites is just one among millions, the individual user can have comfort in the relative obscurity of numbers.  However, what if a potential employer gains access to such information?

The danger with respect to privacy could be if a business shares its "behavioral bank" with organizations with an interest in a particular user.  Such use would not be necessary even in the case of users who want ads tailored to their particular interests. Someone who regularly watches porn might want to know if there is a new sex toy on the market, for example. But should a potential employer such as Walmart be able to access a "behavior bank" to gain personal information on people who have applied for employment?  What if Walmart owns the company that has the bank?  Would not the information then be the property of Walmart?  Furthermore, what if an agency of the federal government were to cite national security to gain access on particular users? Privacy concerns are really oriented to such access concerning particular individuals, typically by third parties, rather than to marketers using pooled data to further segment markets. Legislation ought to be focused accordingly.

In terms of ethical theory, "buying" and "targeting" online users so as to gain and use information that they regard as private violates Kant's "Kingdom of Ends" version of his categorical imperative.  For those of you who have lives and thus do not read Kant, the principle here is that people, being rational beings (i.e,, having the capacity to use reason), should be treated not just as means, but also as ends in themselves. This principle limits exploitation or manipulation of others because using them should not violate treating them as ends in themselves. The reason Kant says for the "ends in themselves" comes down to reason itself having absolute value because we use it to assign value to things.  Just as the sun is the source of light in our solar system, reason is the source of value, according to Kant.  As the source, reason must have absolute, or undefined, value. Incidently, when I get on a topic like this--boiling Kant down and applying his principle to a real-world topic--I think of possibly teaching in spite of my multidisciplinary background (which does not jive well with cubbyholes). Anyway, the rational beings at the online advertising firms seem to be ignoring what the rational nature of online users entitles--specifically, to be treated as an end in oneself rather than merely used.  To be sure, using others is not entirely blocked, as long as it is consistent with treating others as ends in themselves.  In the present issue, users who do not want to be tracked even though that could mean they do not get an informational benefit as consumers are not treated as ends in themselves if they are tracked anyway. We might call it a "boundry issue" on the part of business managers.

In abstract terms, selfishness and greed can prompt a rational being to treat oneself as an end in itself while treating other people as objects. I suspect that this is the root complaint against business managers: that they view humans exclusively as resources while in the role of manager. The problem is that greed is like water running downstream to find wealth below, so an ethical obligation or duty to go around ends in themselves can easily be ignored. Normative constraints do not compute in the business lexicon of greed. I find that people outside of business tend to erroneously project moral principles onto the restricted technical domain of cost/benefit analysis in business. Hence moral claims are made and perceived to be ignored, and a business climate can become toxic. Hence, legislation is typically sought by the general public, even though that route cannot mandate treating others as ends in themselves. We settle, in other words, for temporary dams tantamount to an ethical injunction. In the end, for being moral beings, we humans are remarkably immune to our own nature in the pursuit of what we perceive as our own interests.  In terms of privacy and online data on users, interests particular to a given firm do not recognize "personal boundaries" even as the latter have become salient in modern society. In other words, besides business ethics, business and society comes into play, and of course business and government tends to be the domain in which force or power swoops in to mop up the mess, albeit with thumbs and externally only.


Source: Scott Thurm, "Online Trackers Rake in Funding," The Wall Street Journal, February 25, 2011, pp. B1-2.

See my related essay on the regulation of cookies in the EU: http://thewordenreport.blogspot.com/2011/02/business-and-european-integration-case.html

 

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