A visiting professor from Georgetown University has spent the past week giving us an introduction to medical ethics. We started with the Hippocratic Oath and moved through the ages, passing Beneficence vs. Nonmaleficence, giving a nod to Modern vs Post-Modern theories on the benefit/harm discussion, ending with the conflict between Social Utility and Justice as methods of allocating resources. I nodded my head in agreement for much of the class, right up until the final topic....
As fas as we discussed, we came to define Social Utility as that method which produces as much "net good" as possible considering all affected, i.e. all of society. Justice was aimed at an "end-state pattern" of "good" distribution in a more equitable fashion. I fall easily on the Justice side of things. Justice may not produce as much net good, in fact it most certainly does not, at least in the short term, which is all many people can see. It takes much more effort, resources, and cost to benefit one patient who is severely ill than it does to bump a moderately well patient up to a higher quality of life. Once we factor in socioeconomic status, race, gender, and location of the patient (and possibly other factors) something else is discovered: the patients with the lowest quality of life regarding health tend to be poor, minorities, females, and in rural locations. In order to pursue a Justice social ethic in this case there must be a greater cost input. Social Utilitarians argue that this is pointless - we do less good by focusing on those in worse circumstances. I argue the opposite. Social Utilitarians, reframe the problem!
Autonomy came up again and again in class, and I feel it is at the heart of the issue, especially for Americans. To Americans autonomy is valued above all and has been tried repeatedly in the courts and is found to generally win. The individual rules. It seems to me that in order to improve the health of yourself the most, it would be to your benefit to start by eliminating communicable diseases. This practice is prevalent in veterinary medicine - treat the herd and eliminate disease for all instead of treat one case after case after case. To translate into human medicine this would require a switch from the individual mentality, to one considering the masses. To raise the quality of life for those worst off, would in the end benefit the rest of us.
Consider the case of tuberculosis. According to Medecins San Frontieres (MSF, Doctors Without Borders) 120,000 people die from TB annually. Nearly another half-million cases are diagnosed each year. The hotbeds now are in southern Africa and southeast and central Asia (1). Sure, that is far from America, but if we don't control the problem, how long do you think it will take to reach North America? What with international travel so easy and relatively accessible, how long do you think we can keep TB off our shores? What about Multi-drug resistant TB (MDRTB) and the even newer version, Extensively drug resistant TB (XDRTB)? They're already in the States, actually, just not as prevalent as in other countries. The cases of TB are on the decline in the Sates, but on the rise internationally. This is a great argument for Texans to seal the border, but I don't think that's going to happen anytime soon (nor should it). Do you think it's a better idea to eradicate disease now, for all those infected, and in doing so benefit yourself in the long run? I think so. This is the position of Justice, and Social Utilitarians just consider the long term outcome. Prevent pandemics now by treating those worst off and at risk (which yes, will cost more) and keep yourself safe and warm at night and not in fear of the next person who coughs on you.
1. http://www.doctorswithoutborders.org/news/article.cfm?id=4334&cat=field-news
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