- Philosophy of healthcare
philosophyof healthcareis the study of the ethics, processes, and peoplewhich constitute the maintenance of health for human beings. (Although veterinaryconcerns are worthy to note, the body of thought regarding their methodologies and practices is not dealt with in this article.) For the most part however, the philosophy of healthcare is best approached as an indelible component of human social structures. That is, the societalinstitution of healthcare can be seen as a necessary phenomenaof human civilizationwhereby man continually seeks to improve, mend, and alter the overall nature and quality of his life.
The philosophy of healthcare is primarily concerned with the following elemental questions:
*Who requires and/or deserves healthcare? Is healthcare a fundamental right of all people?
*What should be the basis for calculating the cost of treatments, hospital stays, drugs, etc.?
*How can healthcare best be administered to the greatest number of people?
*What are the necessary parameters for
clinical trialsand quality assurance?
*Who, if anybody, can decide when a patient is in need of "comfort measures" (
Ultimately, the purpose, objective, and meaning of healthcare philosophy is to consolidate the abundance of information regarding the ever-changing fields of
biotechnology, medicine, and nursing. And seeing as healthcare typically ranks as one of the largest spending areas of any government's budget, it becomes rather important to gain a greater understanding of healthcare as not only a social institution, but also as a human phenomenon. In addition, healthcare philosophy attempts to highlight the primary movers of healthcare systems; be it nurses, doctors, hospitaladministrators, health insurancecompanies ( HMOs and PPOs), the government(Medicare and Medicaid), and lastly, the patients themselves.
Ethics in healthcare
The ethical and moral premises of healthcare are convoluted and numerous. In order to consolidate such an enormous field of ethical thought, it becomes necessary to focus on what makes healthcare ethics truly different from other forms of morality. And on the whole, it can be said that healthcare itself is a "special" institution within society. [Norman Daniels, "Healthcare Needs and Distributive Justice," "Bioethics" Ed. John Harris (New York: Oxford University Press, 2001), 319.] With that said, healthcare ought to "be treated differently from other social goods" in a society. [Ibid.] It is an institution of which we are all a part whether we like it or not. At some point in a every person's life, a decision has to be made regarding his healthcare. Can he afford it? Does he deserve it? Does he need it? Where should he go to get it? Does he even want it? And it is this last question which poses the biggest dilemma facing a person. After weighing all of the costs and benefits of his healthcare situation, the person has to decide if it is even worth it. It is not simply economic issues that are at stake in this conundrum. In fact, a person must decide whether or not his life is at its end or if it is worth salvaging. Of course, in instances where the patient himself is unable to decide due to medical complications, like a
coma, then the decision must come from elsewhere. And defining that "elsewhere" has proven to be a very difficult endeavor in healthcare philosophy.
According to French philosopher
Luc Ferry, the field of bioethics represents a "sacralization of the human body," whereby the body effectively "becomes a temple." [Luc Ferry, "Man Made God: The Meaning of Life" (Chicago: University of Chicago Press, 2002), 96-7.] This viewpoint of bioethics is rather interesting for it makes an intrinsic connection between the integrity of the human body and spirituality. Even so, this perspective on bioethics contains a hint of what Ferry refers to as "transcendental humanism," in which reason has succeeded in subverting religion insofar as traditional moralityis concerned. [Ibid, 135.] In a classically French existentialist manner, Ferry proceeds to assert:
Never before, without a doubt, has the progress ofThis assertion can essentially be seen as an effective summary of the philosophical issues raised in bioethics.
scienceand technologygiven rise to questions with such broad moral and, let us dare to use the word, "metaphysical" implications. It is as though the sense of the sacred remains, in spite of the "death of God," but without our being given the spirituality or wisdom that should correspond to it. [Ibid, 96.]
Whereas bioethics tends to deal with more broadly-based issues like the consecrated nature of the human body and the roles of science and technology in healthcare, medical ethics is specifically focused on applying ethical principals to the field of
medicine. It is a large and relatively new area of study in ethics. And one of the major premises of medical ethics surrounds "the development of valuational measures of outcomes of health care treatments and programs; these outcome measures are designed to guide health policy and so must be able to be able to be applied to substantial numbers of people, including across or even between whole societies." [Dan Brock, "Quality of Life Measures in Health Care and Medical Ethics," "Bioethics" Ed. John Harris (New York: Oxford University Press, 2001), 387.] Terms like beneficenceand non-maleficence are vital to the overall understanding of medical ethics. Therefore, it becomes important to acquire a basic grasp of the varying dynamics that go into a doctor-patient relationship.
Like medical ethics, nursing ethics is very narrow in its focus, especially when compared to the expansive field of bioethics. For the most part, "nursing ethics can be defined as having a two-pronged meaning," whereby it is "the examination of all kinds of ethical and bioethical issues from the perspective of nursing theory and practice." [Janie Butts and Karen Rich, "Moral and Ethical Dimensions in Professional Nursing Practice," "Role Development in Professional Nursing Practice" Ed. Kathleen Masters (Sudbury: Jones and Bartlett Publishers, 2005), 66.] This definition, although quite vague, centers on the practical and theoretical approaches to nursing. The
American Nurses Association(ANA) endorses an ethical code that emphasizes "values" and "evaluative judgments" in all areas of the nursing profession. [Ibid, 70.] And since moral issues are extremely prevalent throughout nursing, it is important to be able to recognize and critically respond to situations that warrant and/or necessitate an ethical decision.
Balancing the cost of care with the quality of care is a major issue in healthcare philosophy. In
Canadaand some parts of Europe, democratic governments play a major role in determining how much public money from taxation should be directed towards the healthcare process. In the United States and other parts of Europe, private health insurance corporations as well as government agencies are the agents in this precarious life-and-death balancing act. According to medical ethicist Leonard J. Weber, "Good-quality healthcare means cost-effective healthcare," but "more expensive healthcare does not mean higher-quality healthcare" and "certain minimum standards of quality must be met for all patients" regardless of health insurance status. [Leonard J. Weber, "Business Ethics in Healthcare: Beyond Compliance" (Bloomington: Indiana University Press, 2001), 30.] This statement undoubtedly reflects the varying thought processes going into the bigger picture of a healthcare cost-benefit analysis. In order to streamline this tedious process, health maintenance organizations (HMOs) like BlueCross BlueShield employ large numbers of actuaries (colloquially known as "insurance adjusters") to ascertain the appropriate balance between cost, quality, and necessity of care for a patient. Fact|date=May 2008 Another general rule in the health insurance industry is as follows:
The least costly treatment should be provided unless there is substantial evidence that a more costly intervention is likely to yield a superior outcome. [Ibid, 31.]This generalized rule for healthcare institutions "is perhaps one of the best expressions of the practical meaning of
stewardshipof resources," especially since "the burden of proof is on justifying the more expensive intervention, not the less expensive one, when different acceptable treatment options exist." [Ibid.]
Politics in healthcare
Much has been said with regard to the
political philosophyof healthcare. The debate surrounding universal health careand private health care is particularly potent in the United States. The 1960s however saw a plethora of concrete moves by the federal government to consolidate and modernize the U.S. healthcare system. With Lyndon Johnson's Great Societyinitiative, the U.S. established public health insurance for both senior citizens and the underprivileged. Known as Medicare and Medicaid, these two healthcare programs granted certain groups of Americans access to adequate healthcare services. Although these healthcare programs were a giant step in the direction of socialized medicine, many people think that the U.S. needs to do more for its citizenry with respect to healthcare coverage.Center for Economic and Social Rights. [http://cesr.org/ushealthright "The Right to Health in the United States of America: What Does It Mean?"] October 29, 2004] Opponents of universal health care see it as a dumbing down of the healthcare quality that already exists in the United States. Leonard Peikoff, [http://afcm.org/hcinar2.html "Health Care Is Not a Right,"] December 11, 1993]
Patients' Bill of Rights
In 2001, the federal government of the United States undertook an initiative to provide patients with an explicit list of rights concerning their healthcare. This initiative was essentially taking some of ideas found in the Consumers' Bill of Rights and applying it to the field of healthcare. It was undertaken in an effort to ensure the quality of care of all patients by preserving the integrity of the processes that occur in the healthcare industry. [http://democrats.senate.gov/pbr/summary.html Summary of the McCain-Edwards-Kennedy Patients' Bill of Rights] Standardizing the nature of healthcare institutions in this manner proved rather provocative. In fact, many
interest groups, including the American Medical Association(AMA) and the pharmaceutical industrycame out vehemently against the congressional bill. Basically, providing emergency medical care to anyone, regardless of health insurance status, as well as the right of a patient to hold their health plan accountable for any and all harm done proved to be the biggest stumbling blocks for this bill. [Ibid.] As a result of this intense opposition, the initiative eventually failed to pass Congress in 2002.
Research and scholarship
Considering the rapid pace at which the fields of medicine and health science are developing, it becomes important to investigate the most proper and/or efficient methodologies for conducting research. On the whole, "the primary concern of the researcher must always be the
phenomenon, from which th research question is derived, and only subsequent to this can decisions be made as to the most appropriate research methodology, design, and methods to fulfill the purposes of the research." [Philippa Seaton, "Combining Interpretive Methodologies: Maximizing the Richness of Findings," "Beyond Method: Philosophical Conversations in Healthcare Research and Scholarship" Ed. Pamela M. Ironside (Madison: University of Wisconsin Press, 2005), 217.] This statement on research methodology places the researcher at the forefront of his findings. That is, the researcher becomes the person who makes or breaks his scientific inquires rather than the research itself. Even so, "interpretive research and scholarship are creative processes, and methods and methodology are not always singular, " a priori", fixed and unchanging." [Ibid.] Therefore, viewpoints on scientific inquiries into healthcare matters "will continue to grow and develop with the creativity and insight of interpretive researchers, as they consider emerging ways of investigating the complex social world." [Ibid, 217-18.]
Clinical trials are a means through which the healthcare industry tests a new drug, treatment, or medical device. The traditional methodology behind clinical trials consists of various phases in which the emerging product undergoes a series of intense tests, most of which tend to occur on interested and/or compliant patients. The U.S. government has an established network for tackling the emergence of new products in the healthcare industry. The
Food and Drug Administration(FDA) typically conducts appropriate trials on new drugs coming from pharmaceuticalcompanies. [http://www.fda.gov/cder/guidance/7086fnl.htm Guidance for Industry, Investigators, and Reviewers in Exploratory Drug Studies (FDA January 2006)] Along with the FDA, the National Institutes of Healthsets the guidelines for all kinds of clinical trials relating to infectious diseases. For cancer, the National Cancer Institute(NCI) sponsors a series or cooperative groups like CALGBand COG in order to standardize protocols for cancer treatment. [http://www.cancer.gov/aboutnci/overview/mission Mission Statement of the National Cancer Institute (NCI)]
The primary purpose of quality assurance (QA) in healthcare is to ensure that the quality of patient care is in accordance with established guidelines. The government usually plays a significant role in providing structured guidance for treating a particular disease or ailment. However, protocols for treatment can also be worked out at individual healthcare institutions like hospitals and HMOs. In some cases, quality assurance is seen as a superfluous endeavor, as many healthcare-based QA organizations, like
QARC, are publicly funded at the hands of taxpayers. [http://www.qarc.org/ Quality Assurance Review Center] However, many people would agree that healthcare quality assurance, particularly in the areas cancer treatment and disease control are necessary components to the vitality of any legitimate healthcare system. With respect to quality assurance in cancer treatment scenarios, the Quality Assurance Review Center(QARC) is just one example of a QA facility that seeks "to improve the standards of care" for patients "by improving the quality of clinical trials medicine." [http://www.qarc.org/ Quality Assurance Review Center]
Birth and death
Everybody who wishes to have a child wants it to be perfect (at least at birth). Nobody wants and/or wishes for their child to be born with
Down Syndromeor Cerebral Palsy. In fact, obstetricians have the most medical malpracticelawsuits filed against them. As a result, they have to pay the highest premiums for malpractice insurance. These high costs inevitably become a hindrance not only to the doctors, but also to the healthcare industry as a whole. Where is the regulation? And although patients and their families have the right to appeal and confront a physician regarding the quality of treatment received, there must be a limit as to how far they can go. Frivolous lawsuits are clearly becoming a major problem for healthcare providers.
ecophilosophyof Garrett Hardinconstitutes one perspective from which to view the reproductive rights of human beings. For the most part, Hardin argues that it is immoral to have large families, especially since it does a disservice to society in the sense that there is only a finite number of resources in the world. In an essay entitled " The Tragedy of the Commons", Hardin states,
To couple the concept ofThis statement essentially summarizes Hardin's major point concerning the negligible right of all human beings to procreate. Moreover, Hardin is a vocal critic of the
freedomto breed with the belief that everyone born has an equal right to the commons is to lock the world into a tragic course of action. [http://www.garretthardinsociety.org/articles/art_tragedy_of_the_commons.html Garrett Hardin, "Freedom to Breed is Intolerable," "The Tragedy of the Commons"] United Nations' Universal Declaration of Human Rights( UDHR), which states that "any choice and decision with regard to the size of the family must irrevocably rest with the family itself, and cannot be made by anyone else." [http://www.un.org/Overview/rights.html "Universal Declaration of Human Rights (UDHR)" "United Nations"]
With respect to healthcare philosophy, Hardin's ecophilosophical views may seem like a stretch. Nevertheless, they are important to keep in mind, especially when considering the call for healthcare as a universal birth right of all people. The increasing strains placed on healthcare systems are primarily the result of a growing human population. One way of mitigating healthcare costs is to moderate population growth. The fewer people there are to take care of, the less expensive healthcare will become. And to apply this
logicto what medical ethicist Leonard J. Weber previously suggested, less expensive healthcare does not necessarily mean poor-quality healthcare. [Weber, 31.]
Birth and living
The concept of being "well-born" is not new. On the whole, it takes on a fairly
racistundertone. The Nazispracticed eugenicsin order to cleanse the gene pool of what were perceived to be unwanted or harmful elements. This "race hygiene movement in Germanyevolved from a theoryof Social Darwinism, which had become popular throughout Europe" and the United States during the 1930s. [Naomi Baumslag, "Murderous Medicine: Nazi Doctors, Human Experimentation, and Typhus" (Westport: Praeger Publishers, 2005), 35.] A German phrase that embodies the whole nature of this practice is "lebensunwertes Leben" or "life unworthy of life." [Ibid, 39.]
In connection with healthcare philosophy, the theory of
natural rightsbecomes a rather pertinent subject. After birth, man is effectively endowed with a series of natural rights that cannot be banished under any circumstances. One major proponent of natural rights theory was seventeenth century English political philosopher John Locke. With regard to the natural rights of man, Locke states,
If God's purpose for me on earth is my survival and that of my species, and the means to that survival are my life, health, liberty and property — then clearly I don't want anyone to violate my rights to these things. [http://plato.stanford.edu/entries/locke/#HumNatGodPur John Locke, "Human Nature and God's Purposes," "Stanford Encyclopedia of Philosophy"]Although tarnished by the partiality of
religion, Locke's statement can essentially be viewed as an affirmation of the right to preserve one's life at all costs. This point is precisely where healthcare as a human right comes into the picture.
The process of preserving and maintaining one's health throughout his life is a matter of grave concern. Once alive, how should man proceed in exercising his natural right to preserve his life through good health? At some point in every man's life, his health is going to decline regardless of all measures taken to prevent such a collapse. Coping with this inevitable decline can prove quite problematic for some people. For Enlightenment philosopher
René Descartes, the depressing and gerontological implications of agingpushed him to believe in the prospects of immortalitythrough a wholesome faithin the possibilities of reason. [http://plato.stanford.edu/entries/descartes-modal/#PosHumFre René Descartes, "Possibility and Human Freedom," "Stanford Encyclopedia of Philosophy"]
Death and dying
One of the most basic human rights is the right to live, and thus, preserve one's life. But what about the right to die, and thus, end one's life? Needless to say, this is a very controversial topic. Often, religious values of varying traditions tend to seep into the picture in one fashion or another. Terms like "mercy killing" and "assisted suicide" are frequently used to describe this process. Proponents of
euthanasiaclaim that it is particularly necessary for patients suffering from a terminal illness. [Daniel Callahan, "Terminating Life-Sustaining Treatment of the Demented," "Bioethics" Ed. John Harris (New York: Oxford University Press, 2001), 93.] However, opponents of a self-chosen death purport that it is not only immoral, but wholly against the pillars of reason.
In a certain philosophical context, death can be seen as the ultimate existential moment in one's life. Death is the deepest cause of a primordial
anxiety("Die Anfechtung") in a person's life. And it is in this emotional state of anxiety that "the nothing" is revealed to the person. According to twentieth century German existentialist philosopher Martin Heidegger,
The nothing is the complete negation of the totality of beings. [Martin Heidegger, "What Is Metaphysics?" "Basic Writings" Ed. David Krell (New York: HarperCollins Publishers, 1993), 98.]And thus, for Heidegger, man finds himself in a very precarious and fragile situation (constantly hanging over the abyss) in this world. This concept can be simplified to the point where at bottom, all that a man has in this world is his
Being. And no matter how he proceeds in life, his existence will always be marked by finitude and solitude. The prospect or self-realization that one's life is about to end is quite frightening to say the least. But why is this the case? When considering near-death experiences, man feels this primordial anxiety overcome him. It robs him of his speech and thought, but not feeling. Therefore, it is important for healthcare providers to recognize the onset of this entrenched in patients who are nearing their respective deaths.
Another philosophical inquiry into death centers on the heavy reliance on science and
technologyin the healthcare profession. This reliance is especially evident in Westernized medicine, as it is difficult to make apt connections to primitive means of healthcare in the developing world. Even so, Heidegger makes a rather fascinating allusionto this reliance in what he calls the allure or "character of exactness." [Ibid, 94.] In effect, man is inherently attached to "exactness" because it gives him a sense of purpose or reason in a world that is largely defined by what appears to be chaosand irrationality. And as the moment of death is approaching, a moment marked by utter confusion and fear, he tries to locate a sense of meaning and purpose behind it all.
The manner in which nurses, physicians, patients, and administrators interact is crucial for the overall efficacy of a healthcare system. From the viewpoint of the patients, healthcare providers can be seen as being in a privileged position, whereby they have the power to alter the patients' quality of life. And yet, there are strict divisions among healthcare providers that can sometimes lead to an overall decline in the quality of patient care. When nurses and physicians are not on the same page with respect to a particular patient, a compromising situation may arise. Effects stemming from a "gender gap" between nurses and doctors are detrimental to the professional environment of a hospital workspace. [Mary W. Stewart, "The Social Context of Professional Nursing," "Role Development in Professional Nursing Practice" Ed. Kathleen Masters (Sudbury: Jones and Bartlett Publishers, 2005), 114.]
Aside from role development, another area in healthcare philosophy that necessitates discussion is
palliative care. Otherwise known as hospice care, this area of healthcare philosophy is becoming increasingly important as more patients are preferring to receive healthcare services in their homes. Even though the terms "palliative" and "hospice" are typically used in an interchangeable fashion, they are actually quite different. And the major difference resides in the fact that "hospice care" is a benefit associated with Medicare while "palliative care" is not. [http://www.cms.hhs.gov/center/hospice.asp "Hospice Care Center" "Centers for Medicare and Medicaid Services (CMS)"] As a patient nears the end of his life, it is more comforting to be in a private home-like setting instead of a hospital. Palliative care has generally been reserved for those who have a terminal illness. However, it is now being applied to patients in all kinds of medical situations, including chronic fatigue and other bothersome symptoms. [http://www.capc.org/palliative-care-across-the-continuum/ "Palliative Care across the Continuum" "Center to Advance Palliative Care"]
Ethical problems using children in clinical trials
* [http://democrats.senate.gov/pbr/summary.html Summary of the McCain-Edwards-Kennedy Patients' Bill of Rights]
* [http://www.clinicaltrials.gov/ct2/info/understand Understanding Clinical Trials]
* [http://www.cancer.gov/aboutnci/overview/mission Mission Statement of the National Cancer Institute (NCI)]
* [http://www.fda.gov/cder/guidance/7086fnl.htm Guidance for Industry, Investigators, and Reviewers in Exploratory Drug Studies (FDA January 2006)]
* [http://www.qarc.org/ Quality Assurance Review Center]
* [http://www.capc.org/palliative-care-across-the-continuum/ "Palliative Care across the Continuum" (Center to Advance Palliative Care)]
* [http://www.cms.hhs.gov/center/hospice.asp "Hospice Care Center" Centers for Medicare and Medicaid Services (CMS)]
* [http://www.un.org/Overview/rights.html "Universal Declaration of Human Rights (UDHR)" (United Nations)]
* [http://www.medicare.gov/Default.asp Medicare (The Official U.S. Government Site for People with Medicare)]
* [http://www.ssa.gov/history/briefhistory3.html Historical Background and Development of Social Security; includes information about Medicare]
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