Showing posts with label ethical theory. Show all posts
Showing posts with label ethical theory. 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 AMMSNBC 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.
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Thursday, March 31, 2011
Military Intervention in Libya as Just War: The Catholic Position
0 comments Posted by Find Insurance Online at 1:57 AMAccording to the Catholic Herald, there were originally only three conditions laid down by Thomas Aquinas for a just war:
1) “The war must be started and controlled by the due authority of state or ruler – in other words, it can’t be a civil war or a rebellion. This rules out the war being waged by the Libyan rebels, but not the military intervention of the Nato [sic] forces, since that was indeed started by the due authority, not of one nation, but of the United Nations itself.” Here we see what might be called Aquinas’ implicit Burkean political conservatism with respect to established regimes over what in modern terms we call rights of the people to protest and self-governance. Even under Aquinas’ criterion of due authority of state or ruler, the Libyan rebel movement, as distinct from the preceding unarmed protesting, could be rendered as just provided that there is a rebel authority rather than fractured units fighting on their own. Even by this interpretation, the armed rebels may fall short, at least as they were in March of 2011. Rather than proscribing civil war or rebellion, Aquinas’ criterion could simply be oriented to preventing the unintended additional harm caused by an army in disarray without a clear line of command. In terms of the Libyan rebels, the “unfairness” in a lack of clear command could be interpreted as “unfairness” to the international coalition, whose efforts could be in vain should the rebels refuse to bind themselves under one command. As for the international coalition itself, neither NATO nor the U.N. is a ruler having the due authority of state, for those international alliances or organizations do not enjoy governmental sovereignty. To the extent that the international coalition is based on partners whose militaries are not subject to a common line of authority, the mission may fall short of Aquinas’ criterion. This objection could perhaps be qualified to the extent that the partners meet regularly in common council, whose decisions are adhered to in practice. Other than the objections of the Arab League (and of Turkey in NATO to that alliance taking command), the international coalition may in its conduct have satisfied the criterion. In short, even though both the Libyan rebels and the international coalition could in practice satisfy Aquinas’ criterion here, their qualification is on shaky ground. In both cases, this shortcoming could be overcome by themselves.
2) “There must be a just cause. This wouldn’t include, say, a war for territory, but it would include the protection of a civil population, self-defence and the prevention of a worse evil. The UN resolution emphatically fulfils that condition.” Prime facie, this criterion seems pellucid. However, to the extent that cause can be interpreted in terms of motive rather than outcome, it becomes problematic to assess a given case because it is notoriously difficult, if not impossible, to get into another person’s head. For example, if the Obama administration’s motive, or cause, is to reduce the market’s fears of future disruptions in the oil supply—fears because Libya itself only produces 2% of the global supply—then in terms of motive the cause is not just. However, even here, a “worse evil” could be interpreted as some consumers becoming unable to afford even the gasoline needed to get to work (and the rising cost of food transported to their grocery stores). Perhaps preventing mass poverty (and perhaps starvation and homelessness) could count as counting in obfuscating “a worse evil.” Even so, the protection of Libyan civilians, especially if at the point when they had been unarmed protesters, would be a more immediate prevention of a worse evil because such protection follows directly from Qaddafi’s violent betrayal of his own people. Alternatively, moreover, if the decisive element is outcome or consequence, the fact that hundreds of thousands of Libyan civilians have been spared as a result of the allied bombings would satisfy the criterion. In my view, the criterion applies to both motive and consequence. In the Libyan case, the fact that it took the Obama administration a month to respond militarily—after the protesters had given way to armed rebels and the price of oil had spiked on world markets—can legitimately be used to assess motive from the standpoint of just war theory. Were Obama’s primary motive the protection of Libyan civilians, he would have intervened when Qaddafi violently turned on the protesters. As Obama himself said, Qaddafi had lost the legitimacy to rule.
3) “The war must be for good, or against evil. Think what Gaddafi said when he thought his tanks were about to roll virtually unopposed into Benghazi: that he would go ‘from alley to alley, from house to house, from room to room’ and that he would show no mercy’. Thousands would have died. Without any doubt, the airstrikes have been against a very great evil indeed.” This criterion is closely related to the second—the criterion going from “just” to “good” (as opposed to evil). The shift here is from just war as under ethical auspices to a theological basis. The book of Job in Hebrew scripture attests to the vital difference between the two. Theoretically, God cannot be omnipotent if conditional on observing an ethical system. In other words, the “good” theologically cannot be held ransom for the “good” ethically. Divinity transcends mere human (i.e., finite) systems. Hence God is said to be wholly other even as it is immanent in the very existence of creation. In terms of the Libyan case, the question of motive and consequence is relevant here too. In terms of motive, is the protection of consumers to obviate an evil, or is it merely a matter of convenience and fairness (to the consumers being impacted by the speculators and fear in the market)? Regarding Qaddafi’s intended action, the sheer magnitude of it could point to it being evil even as a stated threat; it is certainly unethical. However, to treat such suffering itself as pointing to an evil action risks reducing theology to ethics (harm itself to the absence of God). In other words, evil cannot be merely unrequited and unjust suffering. Perhaps the question of evil goes to the intent of the agent of the deed involving treating himself as a god, with the suffering of others being an effect of the conflation of the creature with the Creator. As with the matter of motive more generally, the problem may be in judging another person to be evil. “Thou shalt not judge”. . . but the intensity of inflicting injury tends to speak for itself. Lest our finiteness as human beings render us impotent to prevent or stop evil, we adopt such surrogates as a matter of necessity. In terms of stopping Qaddafi from murdering on a large scale (though are more lives worth more than a few?), the reaction of most of the rest of the world can be read as a rejection of evil, for Qaddafi did seem to take on god-like aspirations in having such power over life and death.
According to the Catholic Herald, “The Church later added two more rules, though St Thomas usually gets the credit for them (and why not?). The first is that the conflict must be a last resort. In other words, every other option must be tried first. In this case they had been. Sanctions, diplomacy, phone calls from Tony Blair to his pal Muammar, freezing of assets, the lot. None of it had any effect. The UN military measures were not only a last resort, they were employed only at the last possible moment, just in the nick of time.” Significantly, “last resort” does not necessarily means “after due time.” The timing of the response, and thus the alternative options available, must surely be impacted by the nature of that which is to be prevented. For example, if a ruler is violently turning on mass protests, waiting for the go-ahead from the Security Council may not be a justification for not acting immediately. The fact that the Council does not have governmental sovereignty (e.g. five permanent members have vetoes) means that the body is not equipped to act on short-notice. This fact mitigates the claim that a U.N. mandate is morally (or theologically) of value before an evil can be prevented or stopped in its tracks. If the purpose of the international coalition’s intervention in Libya was to protect civilians, a timely response was implied because of the nature of Qaddafi’s action against the protesters. Excessive delay could be interpreted as an implicit complicity in the evil if more immediate intervention was possible. In short, last resort does not necessarily imply delay.
The Catholic Herald describes the last criterion of Catholic just war theory as follows: “Lastly, the war must be fought proportionally. This means that more force than necessary must not be used, nor must the action kill more civilians than necessary. Enormous pains are being taken to fulfil this condition, too. The supposed “smart bombs” they talked about in the first Gulf war (which constantly missed their targets and killed large numbers of civilians) appear to have been in the last 20 years perfected in the most remarkable way, so that tanks can be taken out surgically even inside urban areas without damage to their surroundings (special missiles are used, with a considerably reduced explosive charge).” Here, the purpose of the international intervention is crucial. If the end is to remove Qaddafi because he has lost the right to rule by international consensus, then the no fly zone acts are not proportionate. However, the actual agreed-upon objective of the coalition (as per the Security Council’s resolution) does not reach regime change. In terms of protecting civilians, that Qaddafi’s forces continued to beat and kill civilians after the imposition of the no fly zone strongly suggests that the coalition’s intervention was not proportional. Divisions within the coalition on this point could thus be interpreted as contrary to just war from the Catholic perspective.
In summary, even though my analysis of the Catholic Church’s just war criteria is generally consistent with the judgment expressed in The Catholic Herald article, my particular stress is on the extent of nuances and how they qualify the judgment. Moreover, the nuances raise theoretical questions that transcend the matter of just war. Among such matters is that of the relationship between human judgment (and ethical systems) and the divine. Just war theory can be viewed as presumptuous to the extent that it presumes a judgment on matters that transcend the boundaries of human cognition and perception. Even so, as human beings living in human societies, we are as though instinctively drawn to stop what seems to us to be evil to us even if we cannot be sure of our judgments. As is the case more generally on matters where theology meets the ground, we are in the condition of “already, not yet.” Accordingly, a good supply of humility is called for even when we are convinced that we are fighting evil rather than perpetuating it.
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