Normative Theories in Ethics: Bioethics and the Right to Healthcare

Introduction to Applied Ethics and Bioethics

Transition to Bioethics: The course is moving from normative theories in ethics into a specific component on philosophy in healthcare, known as bioethics. This represents a shift into applied ethics.
The Emotional Nature of Applied Ethics: Discussions in applied ethics, particularly in Canada, are frequently emotional and passionate. While passion is common in many ethical topics, it often mirrors the intensity seen in political discourse, sometimes leading to a breakdown in social conversation.
The Role of Philosophy in Cutting Through Emotion: * Philosophical ethics attempts to cut through emotions. This does not mean ignoring them, but rather preventing them from overwhelming the participants or destroying the conversation. * It seeks to address and look past raw moral intuitions—those immediate feelings of right and wrong that people often cannot explain. * The goal is to prevent moral discussion from becoming merely a "pounding of the fist on the table."
Foundation in Evidence and Reason: * Philosophical discussion is based on evidence and reasoning. In this context, "arguing" means presenting evidence for a specific view. * Case Example (Wong): The philosopher Wong argued for relativism not by appealing to emotion, but by offering a theory he believed provided the best explanation for moral disagreements across different cultures and time periods.
Theoretical vs. Empirical Inquiry: * Ethics is abstract and difficult compared to the hard sciences. * Unlike science departments, ethics cannot always rely on empirical lab tests; instead, it utilizes thought experiments and abstract reasoning.
Cautionary Note on Education and Emotion: * There is often an inverse relationship between education on a topic and dependence on emotion. Those with less education may overcompensate by letting feelings dictate their views. * Feeling a certain way about a topic does not make that feeling true. Subjectivism (the idea that truth is relative to individual feelings) is rejected in this philosophical context.

The Sociopolitical Perspective on Thinking vs. Feeling

Thomas Sowell Quote: The sociopolitical philosopher Thomas Sowell stated: "The problem isn't that Johnny can't read. The problem isn't even that Johnny can't think. The problem is that Johnny doesn't know what thinking is. He confuses it with feeling."
Implications of Conflating Thought and Feeling: * Confusing thinking with feeling leads to high costs: ignorance and the breakdown of dialogue. * If a person believes their views are correct and important, they should actively seek to prevent dialogue from breaking down. Yelling or emotional outbursts are often signs of overcompensating for a lack of understanding.
Intellectual Humility: Students are encouraged to entertain the possibility that they could be wrong, especially if they lack formal education or research in a specific area. Admitting one is "dead wrong" is a valid and useful part of the ethical learning process.

Course Structure and Ethical Difficulty

Addressing "Hot Topics": The course will cover difficult, "morally repulsive," and skin-crawling topics, including life-and-death scenarios and sexual violence. Healthcare ethics is not always "neat and tidy" or pleasant.
Methodology of Presentation: * The instructor presents at least two views (a "for" and "against") on every topic. * The Problem of Primacy and Recency: Students shouldn't let the first speaker or the last speaker (the one providing the criticism or reply) be the most authoritative. The stopping point of a lecture is often a matter of time, not an indication of which side is more "correct."

Access to Healthcare: Rights and Obligations

Central Question: "Is there an obligation to provide access to healthcare?"
The Canadian Context: Many Canadians take for granted two closely related concepts: 1. Citizens have a right to healthcare. 2. Others (society/the state) are obligated to provide that healthcare.
The Philosophical Inquiry: Ethics moves beyond the popular or "shallow" view (e.g., "I like healthcare") to ask if there are good, relevant reasons to hold that this right and obligation actually exist.

The President's Commission: Thesis and Foundations

Core Thesis: There is a social obligation to provide everyone with an "adequate standard of care" without "excessive burden."
The Importance of Healthcare: * Healthcare is widely recognized as essential for promoting personal well-being. * It prevents and relieves pain, suffering, and disability. * It prevents and mitigates the loss of life. * It provides opportunities for individuals to pursue their goals and life plans, similar to the value of education.
Healthcare as Education: Many patients do not understand the nature of their own health problems. A key aspect of healthcare is educating people on their conditions, treatments, and how to function in life.
The Unifying Nature of Health: All humans are vulnerable to disease and death regardless of culture or time. Interest in health is universal among humanity.

Three Conceptions of "Equitable Access"

Model 1: Equity as Equality: * Interpretation A: Everyone receives equal healthcare dollars to spend. * Interpretation B: Everyone enjoys equal health status (personal health is equalized). * Interpretation C: Everyone is provided the same level of healthcare. If a treatment is not available to everyone, it is available to no one. * Critique: This is likely impossible to enforce without violating personal liberty (the freedom to spend one's own wealth on health). It could lead to a "black market" for healthcare. Based on Rawls’ original position, this position is often viewed as irrational because it ignores the principle of liberty.
Model 2: Equity as Benefit or Need: * Everyone must receive all healthcare that is beneficial to them or needed by them. * Critique: This model is unrealistic because resources are limited. Providing unlimited access to anything that could benefit someone would place an unacceptable burden on society. Since healthcare is expensive, more resources for one person means fewer resources for education, infrastructure, or the environment (an opportunity cost).
Model 3: Equity as Adequate Level of Healthcare (The Commission's Preferred View): * Everyone must have access to enough healthcare to achieve sufficient welfare, opportunity, information, and education to facilitate a "reasonably full and satisfying life." * Strength of Ambiguity: While the term "adequate level" is vague, this is considered a strength. It acknowledges that healthcare is limited and must be prioritized against other social goods. * Individual Liberty: This model does not violate individual liberty because people are still free to use their own resources to purchase more than the "adequate level" if they wish.

Social Obligation vs. Individual Responsibility

Healthcare as a Social Product: * The President's Commission argues that individual people are not personally obligated to provide healthcare; it is a community responsibility for three reasons: 1. It requires social cooperation, skills, and efforts that no single individual can provide alone. 2. Health needs are unpredictable, uneven, and expensive. 3. Health status is often outside of an individual's control (the "natural lottery").
The Challenge of Personal Responsibility: * While it seems reasonable to hold people accountable for voluntary, informed choices that lead to poor health (e.g., smoking or alcohol), it is theoretically difficult to do so. * It is hard to determine if a person was truly "fully informed" due to misinformation. * It is hard to determine if a choice was truly "voluntary" (e.g., in cases of addiction). * Genetic predispositions often blur the link between behavior and health outcome.
Fair Share and Individual Obligation: Despite the difficulties, the Commission suggests it is appropriate for individuals to be responsible for a "fair share" of the cost of their health. If society provides the safety net, the individual has a corresponding obligation to take care of themselves so as to not take advantage of the generosity of fellow citizens.

Practical Implementation and Burdens of Access

Variable Nature of "Adequate Care": Because health status is a lottery, "adequate care" is not a fixed list. It changes based on: * The specific needs of the individual. * The availability and cost of treatments over time. * Comparisons of cost and benefit between competing treatments.
The Meaning of "Equitable Access": Providing a right to care means providing it without "excessive burden." * Example of Burden: If medical care is available but requires a $10\,\text{hour}$ drive, a $10\,\text{hour}$ wait time, and a significant portion of a person's finances, it is not truly equitable access. Excessive financial burden eliminates the very life opportunities healthcare is meant to provide. * Standard of Delivery: Healthcare must be delivered in a setting appropriate to the recipient. This might vary (e.g., delivery via helicopter in remote areas), and delivery methods to one group may look very different from delivery to another.
Conclusion on the Right: The President's Commission concludes that healthcare—specifically an "adequate level" of healthcare—is a right. This right does not necessarily mean the care must be "free," but it must be provided without excessive burden to the citizen.