Health Care & the Common Good:
Dr. Edmund Pellegrino
Chairman of the President's Council on Bioethics, Dr. Pellegrino begins the conference with thoughts on the state of health care in the U.S. The debate about health care ethics in America has gone on for a long time and for the most part it has been argued in terms of economics, finance and practicalities - all important. But Pellegrino suggests that maybe these questions are secondary to other ethical matters. What obligations do we have to the ill? What does a good society owe to it's citizens? How do we judge among the programs available that we are meeting society's needs? How do we determine that we are a good society in this regard?
Health care for the common good, what does it mean? Many people move from reason to emotion in addressing this question. Pellegrino goes through 3 theories, Aristotelean, Liberal, and Communitarian perspectives on the common good.
All human beings have an inherent dignity that comes from the fact that they have been created equally. Agreed upon by the United Nations. The common good does not discriminate because we are all human beings.
What are some conditions for the common good? Everyone needs them, and someone needs to provide them. These are some elements
1. Security
2. Privacy
3. Education
4. Tolerance
5. Interaction
6. Freedom
7. Health
8. Peace
9. Medical care
10. Interaction
Objections to health care as the common good: why should we care for those who don't care for themselves? We must allow for the flourishing of every human being.
Can we be part of the human community if we are denied health care as a common good?
Benevolence is more important to a good society than autonomy. Not helping the sick undermines the kind of society we want to be (Adam Smith)
The function of a society as a whole is to preserve the above elements for a human being to flourish as a human being.
Mark 1:34 And he healed many who were sick with various diseases, and cast out many demons. And he would not permit the demons to speak, because they knew him.
"We have one virtue, that is the virtue of charity." Dr. Edmund Pellegrino
"With ethics alone you'll neither satisfy God nor fulfill your intrinsic possibilities. God is the Holy One. Goodness is one of the names of him whose essence is inexpressible. And he desires not only obedience to the commands of the 'abstract good,' but also your personal affection. More, he wants you to risk love and and the new existence that springs from it. Only in love is genuine fulfillment of the ethical possible." The Lord by Romano Guardini
First order question of a good society, obligations to see that people have what they need.
The notion that we are interconnected as human beings, we have responsibilities to each other. What happens to one happens to the rest of us. Whenever we can do something to recognize that we are members of a conjoined society, that is why the the common good is so crucially important.
Closing statement: Do we want to be passive bystanders? Do we not want to contribute to the relief of those who suffer? Is the picture we give....do we want to be seen as doing the Pontius Pilate act and not taking responsibility for others? What kind of society do we want to be?
Question: Has there been any official reaction to the article by Steven Pinker on the uselessness of human dignity?
Response: (Qualified as own opinions) Not a very intellectual engagement of ideas.
Question: Systems are not the answer...?
Response: First order questions are ethical/theological. IOW, what does it take for a society to pursue the common good? It's never been defined in the public arena. So which systems are helpful with regard to their ethical content. It's about getting clarification on the ethical implications of systems.
Question: The obligations to provide health care for people in need and suffering....how far does this extend?
Response: One of the conditions would have to be that any medical treatment that we're going to use or include...is going to have to be proven as effective. But are we committed to health care as a common good as an ethical concern or economic concern? Health care cannot be a commodity and the marketplace has no heart. We give it a heart by thinking about our obligations.
Patient Perspective (Clinical Ethics):
"Common Good" Case for Today
Moderator: Robert Orr, MD
Panel: Sam Casey, JD; John Dunlop, MD; Pat Emery, MSN, RN; Daniel McConchie, MA; and Pastor Keith Plummer, PhD (Cand)
Clinical ethics looks at the patient with the obligations of beneficence and compassion.
Case: Peter is 10 3/4 years old. 2 months - severe cardiomyopathy. 7 months received heart transplant. 27 months, severe rejection episode with cardiac arrest and hypoxic brain damage. Now he has markedly diminished renal function. Transplant? sever coronoary artery disease. Re-transplant?
KP - Are there other children?
RO - Mom is single, no siblings
PE - What does Mom want?
RO - let's assume she will want to pursue these things?
DM - What is the prospect for longterm dialysis?
RO - Covered by medicaid,
JD - Other issues with new organs?
RO - Kidney's might quit earlier than heart, likely not a combined transplant. Each transplant has a high chance for success.
SC - if successful, what is the longterm prognosis?
RO - Rest of body seems to be functioning well. Nothing in particular anticipating to take his life in the forseeable future.
RO - Mom wanted more education to care for him. Son is in institution and she cares for him on weekends. Mom content with his level of function.
DM - Child's level of cognition?
RO - Nonverbal. First able to sit at age 4. now he can walk with assistance. Can drink from a cup but needs assistance with self-feeding. Is in diapers, doesn't speak. Tries to mimic sounds. Loves music.
PE - Mother's support system?
RO - well connected
PE - mother's level of education?
RO - high school/college
SC - Concern: child is profoundly disabled. Other child on transplant list are otherwise normal. Are their listing criteria?
RO - Criteria: Adequate, cognitive attention.
SC - does this listing violate American's with Disabilities Act?
RO - What if this child were in PVS?
SC - if the child is PVS, that doesn't mean that the AwDA doesn't apply.
RO - Allocate upon some neutral criteria? Is there discriminatory criteria that the law points out?
Other questions/comments:
Something within this child that keeps him alive.
How much would all this cost. Public money that might be spent on more otherwise healthy children?
Has he had seizures? No
What is the relationship between his suffering and what he might have to gain?
Is that appropriate given his cognitive state?
Does he recognize his mother and respond differently to other people?
Is he in crisis right now? (no)
...the discussion continues...
Professionalism in Peril:
Dr. Gene Rudd
When we lose sight of our core values, we risk moral meltdown in health care.
Professional adultery-medicine has its mistresses. More physicians now are employees rather than partners in private practice. Do those institution share our moral obligations? Are patients merely customers?
Autonomy-We have given it such priority that it comes without warnings. In a relativistic society we have a moral obligation to communicate the "thou shall not's."
Transition from covenant to contract - a move from moral obligation to legal obligation. Trust is an essential part of health care, but trust is eroding.
Dr. Gene Rudd is from the Christian Medical & Dental Association and provided a very insightful plenary talk on professionalism in health care and what that means from the perspective of our Judeo-Christian tradition.
Health Care in the United States: Strengths, Weaknesses, and the Way Forward
James C. Capretta, Ethics and Public Policy Center
Ethics & Public Policy Center.
US health care is employment based. Employer participation protects private sector orientation and innovation.
If you get down to it, what's happening is the ability to organize care for the patient is difficult.
Pushing health care down to the state regulatory level is crucial.
Ancillary Care Perspective:
Deadly Denial of Dental Care (Case Study)
Moderator: Dr. Claretta Dupree
Panelists: Eileen Clark, Pat Emery, James Grear, Rochelle Moore, Barbara White
Overall health requires good oral health. In what way can society provide more access to dental care. Where does the moral obligation to be concerned with the common good come into play? Is there a professional obligation or does it land squarely in the domain of Christian values.
This has been an enlightening discussion on the topic of dental health, leading to more worldview questions. Christians don't have the corner on benevolence, but the Christian worldview makes sense of the good, gives it meaning.
If we can't get our community leaders and key people actively involved in advocating for those in need, how can we help? It isn't just about Christians, advocacy needs to be a community solution. And the solution can't always be about working harder, but worker smarter in as much as existing systems permit, though recognizing shifts must eventually occur in the existing systems.
Health Care & the Common Good:
Dean Clancy (Solutions)
Definitions:
1. The good of the whole community
2. The highest good for each of us
3. Communal virtue and happiness, built upon the virtue and happiness of individuals, families, towns, etc.
Levels
1. First order questions (what is right or just?)
2. Second order questions, what should be done?
3. Both sets of questions require debate, deliberation and participation by citizens.
Problems in health care
1. Rising costs and coverage gaps
2. Changing roles and declining professionalism of caregivers
3. Ethical quandaries arising from science and technology
4. Cultural and political problems
Clancy points out that medical inflation must end and that government's share is about 1/2 and growing.
Jim Capretta's Four-Point Plan
Cap tax exclulsion, create limited tax credit
Give states regulatory flexibility, with state "exchanges"
Convert Medicare into a form of defined contribution
Implement incrementally
Dean Clancy Additions
Completely relieve states of Medicaid spending burden
Combine Medicare and Medicaid into a single federal program based on poverty and disability rather than age. No more Medicare benefits for millionaires and billionaires.
Question:
Would you put a cap on medical malpractice suits?
Response: Would all caps be just? More consideration must be given to the victims of medical malfeasance.
Health Care & the Common Good: Dr. Peter Lawler
Peter Augustine Lawler is Dana Professor and Chair of the Department of Government and International Studies at Berry College. He teaches courses in political philosophy and American politics and has won several awards from Berry for doing so.
A truly progressive society would subordinate technological process to personal progress.
John Locke - "My body is my property"
Autonomy trumps in our culture.
Locke - In an individualistic society, the only hold the older people have on the young is money.
Immediate crisis in health care is productivity over care giving.
Care should be given in the most personal way possible, knowing that each human being is more than a human being with interests.
Health Care & the Common Good:
Dr. Edmund Pellegrino (Final Thoughts)
All the dimensions of politics and the health care system are designed to care for the individual. Health is a desirable end, medical care is a need.
Should religion be engaged in the dialectical discourse? As Pellegrino discusses this I'm reminded of the works of H. Tristram Engelhardt discussing the role of religion in the public square and the notion of agreement among "enemies."
Autonomy started as a negative right but has become from a right of neglect to a right to demand treatment to the extent of micromanagement at the bedside. While wanting to preserve the autonomy of the patient, we also need to consider the autonomy of the health professional.
In clinical ethics, there need to be absolutes. Without them, morality will be left to the courts.
Augustine says 'an unjust law is no law.' Today conscience clauses are under threat and the value-free doctor is the most desirable.
Pellegrino very interestingly recommends bedside clinical ethics education. It takes a socratic approach, takes it out of the abstract and into reality. It seems this approach brings the clinician into a more intimate relationship with the patient.
"Inane thinking" about the hippocratic oath that pervades bioethics today. Pellegrino says that the hippocratic oath/ethos are not the whole of medical ethics. It is a statement of morality.