1. Macroallocation of Resources Is There a Right to Health Care?

2. Macroallocation and microallocation Macroallocation: what is just use of society’s (world’s?) resources for health care? Do people have a right to health care? Should wealthier get better health care Microallocation: clinical decisions involving particular people Who should get the ventilator? Who should live when not all can live? Should social worth be considered in allocating scarce resource?

3. Disturbing Facts Health care costs rising rapidly Technological improvements promise new treatments but add expense US spends about 18% of its wealth on health care, much more than comparable countries US behind many other countries in life expectancy infant mortality rate Number of people without health insurance rising. Great inequality in health within US

4. Life Expectancy by Race/Ethnicity THE MEASURE OF AMERICA | AMERICAN HUMAN DEVELOPMENT REPORT 2008–2009

5. Global Health Comparisons, Healthcare Spending THE MEASURE OF AMERICA | AMERICAN HUMAN DEVELOPMENT REPORT 2008–2009

6. Global Health Comparisons: Life Expectancy THE MEASURE OF AMERICA | AMERICAN HUMAN DEVELOPMENT REPORT 2008–2009

7. Infant Mortality: If the U.S. had the rate of the top-ranked country (Sweden), over 21,000 American babies would have lived to celebrate their first birthday.

8. 1998 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1998, 2007 (*BMI 30, or about 30 lbs. overweight for 5 ’ 4 ” person) 2007 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

9. Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14%

10. Obesity Trends* Among U.S. Adults BRFSS, 1986 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14%

11. Obesity Trends* Among U.S. Adults BRFSS, 1987 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14%

12. Obesity Trends* Among U.S. Adults BRFSS, 1988 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14%

13. Obesity Trends* Among U.S. Adults BRFSS, 1989 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14%

14. Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14%

15. Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19%

16. Obesity Trends* Among U.S. Adults BRFSS, 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19%

17. Obesity Trends* Among U.S. Adults BRFSS, 1993 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19%

18. Obesity Trends* Among U.S. Adults BRFSS, 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19%

19. Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19%

20. Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19%

21. Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19% ≥20%

22. Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19% ≥20%

23. Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19% ≥20%

24. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19% ≥20%

25. Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

26. (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) Obesity Trends* Among U.S. Adults BRFSS, 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

27. Obesity Trends* Among U.S. Adults BRFSS, 2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

28. Obesity Trends* Among U.S. Adults BRFSS, 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

29. Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

30. Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

31. Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5 ’ 4 ” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

32. Questions What proportion of national wealth should go to health care compared to other needs (e.g., education, environment, defense)? Of amount that goes to health care, what proportion should go for Treatment? Preventive measures? Research? Do people have a moral right to health care? How much? How active should government be? (NYC limits size of sodas)

33. Part of larger debate on economic justice On what basis should some people have more wealth than others? Do wealthier people deserve their greater wealth (and what goes with it)? Why would basing wealth on race or sex be wrong?

34. Economic justice in general Ethical principle: people ``should not have greater wealth or privileges due to facts over which they have no control. On what basis do people have greater wealth now and how much is under their control? Effort Intelligence (native and acquired) Family circumstances One central issue: a continuum between economic liberty and economic equality

35. Utilitarian approach Wealth should be distributed in a way that maximizes the greatest happiness for all. Criticized as ignoring justice, the distribution of benefits and burdens. Utilitarian approach could allow some to benefit at the expense of others (e.g., great medical care for the few; none for others)

36. Rawls’ approach: A Theory of Justice Against utilitarianism Imagine we are forming a society and determining rules. We are in the “original position” Everyone rational Everyone self-interested Key: we have a “veil of ignorance” over us: we don’t know our particular human qualities: sex, race, genetic endowment. Rules we would decide unanimously in this position are just rules.

37. What Rules Would We Adopt? Start with equality Accept inequality if and only if it would benefit everyone, in particular the least advantaged. Maximin: people would not risk worst outcomes; would choose “maximum minimum” Objections from both political sides: Economic conservative: capitalism benefits the greatest number and is justified even if poorest are sacrificed. Socialists: inequality is bad in itself

38. Medical Individualism: Sade Extreme emphasis on economic liberty (not equality) Medical care is a service to be bought and sold Basically a Libertarian (political party) position. Most important right is right to property.

39. Strategies for Arguing Against Sade and Pure Free Enterprise The free enterprise system as a whole is morally unsound due to economic injustice. Inequality and property rights in many areas are acceptable but health care is different and special. Why? See President’s Commission Report, a crucial reading.

40. Are there PUBLIC goods? Are there some things that a society should treat as “public goods,” not part of free enterprise system? Things that people should get regardless of ability to pay. See “Public and Private Goods” http://www-personal.umd.umich.edu/~elias/pub-pri.doc

41. President’s Commission (1983) Securing Access to Health Care: A Report on the Ethical Implications of Differences in the Availability of Health Services

42. Health Care Is Special Because of its Relation to… Well being Avoidance of pain, suffering, disability, death. Health care a primary good: something we desire regardless of our particular life goals Opportunity Information Existential significance of illness, birth, death

43. Other Factors Making Health Care Special Need for it is not predictable; can’t easily plan for it Much of health and illness is beyond individual control: genetics, environment, chance. Cost of care can be overwhelming (e.g., unpredictable catastrophe from accident)

44. Spirit of Report (contrast with Sade) “The depth of a society’s concern about health care can be seen as a measure of its sense of solidarity in the face of suffering and death.” “A society’s commitment to health care reflects some of its most basic attitudes about what it is to be a member of the human community.” We should provide equitable access to health care, but what is “equitable”?

45. To save a life? "... whosoever saves a single soul is regarded as though he saved the whole world." --Talmud, Sanhedrin 4:5, Danby translation (Judaism) " if anyone saves a life, it shall be as though he had saved the lives of all mankind." -- Koran 5:37 (Islam)

46. Equity is not equality (equality would mean: “whatever one gets, everyone gets”) If generous, too great a drain on nation’s resources that are needed for other goods. If restrictive, then would need to restrict economic liberty (p. 532-1) (recall chart distributed in class) Wealthy could use their greater wealth for frivolous things but not for better health care for their children. Is this unjust?

47. Equity is not providing all that would benefit people Too expensive; must consider costs as well Cannot even provide all that people “need” because need to hard to define. Philosophically: important distinction between wants and needs Can this be formulated in a way to overcome the Pres. Commission’s objection here?

48. Equitable access should provide an adequate level of care Task: sharpen this vague term into a workable foundation for U.S. health policy Recognizes that resources are limited; we need to set priorities Overcomes objection that equitable health care is an “impossible ideal.” Avoids an unacceptable restriction on economic liberty (e.g., disallowing rich to spend for health care) This notion is “society-relative. Interesting to consider how we’d define “adequate” in South Africa

49. Other views Libertarian: NO public responsibility Daniels: “normal species functioning” Gutmann: equality: health care so related to human dignity that any inequality is immoral. Utilitarian Rawls: what would be decided in original position

50. Other Key Elements Should impose only “acceptable burdens” on people The obligation to provide equitable health care belongs to society This is a public, communal responsibility Contrast with Sade.

51. Why is health care not a private responsibility? Cannot be provided by individuals’ own efforts Unpredictable and great costs Undeserved (generally); p. 534. (But what about the parts that are—e.g., heavy smokers?) (Above repeat earlier points. But also, not explicitly stated but important—EB): Medical knowledge has been acquired with public funds, so doctors’ skill is not their private property. (“a social product requiring the skills and efforts of many individuals”)

52. What Is the Role of Government? A social responsibility, but not necessarily only government: a “pluralistic approach of public and private.” The ultimate responsibility for health care rests with the Federal Government. (Doesn’t mean government should be provider)

53. Defining “adequate” level Does not mean the highest possible level of quality. So there may be an expensive treatment that will provide best care that will have to be denied. Outcomes research has become increasingly important (EB) Dialysis costs today: should we impose restrictions on whom to treat?

54. Which factors legitimate in rationing? Obviously legitimate: necessary (but not sufficient condition): the treatment will produce benefits [not futile] Obviously NOT legitimate: race or sex of person (unless related to likelihood of effective treatment)

55. Which factors legitimate in rationing? Willingness of patient to pay extra? Age of patient: who would get highest priority? Quality adjusted life years rather than just number of patients or years of life? Past expenditures on patient? Family role? Likely future contributions to society Past contributions

56. Whose life has priority to be saved, all 30 years old and costing same amount to save? Patient A: Treatment would produce 20 years of normal life Patient B: Treatment would produce 20 years but patient would not be able to walk Patient C: Same as B except C is already unable to walk, so treatment would not change that condition Patient D: Treatment would produce 20 years of life on dialysis Patient D: Same as D, but on ventilator Patient E: Same but semi-conscious, in nursing home

57. Subject to cost-benefit analysis Consider what else is not being done (other medical and non-medical goods) Does not guarantee highest level of quality Take broad view of benefits, including reassurance from worry and communal solidarity