The Capabilities of Individuals and a Holistic Sensation of Health in Health Care - Research Paper Example

Capabilities, Social Goods, and the Virtuous Good Life: Medical Ethics and the Good [ID In a sense, all of humanitys needs center on medical care and related concerns. Being healthy and free of pain is the prerequisite for human happiness and survival. Even the Dalai Lama argues in Ethics for the New Millennium that, while spiritual and psychological development and the ethical life is deeply important, certainly basic medical care is a necessity to free people from suffering. Thus, questions about the moral approach and analytical philosophy behind health care are essential, and answering them affirmatively is the only way to protect patients. Two of the most common analytical philosophy approaches are the social goods approach, emphasising goods society produces (such as the service of medical care and the goods of drugs and medical supplies), and the capability approach, emphasizing the full and harmonious development of human needs and capabilities (Brighouse and Robeyns). But these approaches are not complete. The capability approach addresses issues of humanitarianism, not justice, while the social goods approach is too economistic both in its metaphors and in its actual focus; autonomy, freedom, community and institutional concerns and achieving the highest and most virtuous life are still worthwhile and not lexically below issues of justice, and health care philosophy should represent this. Why is health care philosophy concerned about these relatively abstract notions of justice? Simple. “Justice is frequently in the background of debates about health care access, financing, and delivery in the United States and elsewhere. Is it just to have as many uninsured citizens as we do? Are disparities in health care access between ethnic and social groups fair? Does an employer-based approach to health insurance qualify as just when not everyone works for an employer that provides it? These are just a few of the fundamental questions that can be, and are, asked of health care in the United States” (Powers and Faden). While in Britain and Europe these matters are somewhat more settled, certainly there are still issues. How much is plastic surgery a right? Surely some plastic surgery is wholly for self-aggrandizement. But certainly a transgendered individual seeking out a sex change operation is attempting to express their identity, and a serious question must be asked when we choose to deny it. Should there be parity between mental and physical health care? Questions of distributive, remunerative and social justice are tied in intrinsically to medical care. The first issue is that the two approaches are not actually logically or necessarily mutually exclusive or opposed (Brighouse and Robeyns). Social goods provide for the capabilities of people to develop themselves fully. Capabilities are one of the ways we measure the effects of social goods, and whether they are social primary goods or not. Even if one approach were more coherent or useful, why adopt one over the other? The second is that both approaches are sharply incomplete. Let us take the capability approach, then the social goods approach. The capability approach is defined by Comim et al as “The proposition... that social arrangements should be primarily evaluated according to the extent freedom people have to promote or achieve functionings they value. Put simply, progress, or development, or poverty reduction, occur when people have greater freedoms”. The bevy of questions is immediate to the trained observer. Why must we recognise freedom as the core value? This is both culturally imperialist and philosophically arbitrary. Americans and Europeans might highly value freedom, but other cultures value community structures, or equality, or fraternity, far more. Theres even substantial variation on the Continent. Brits have always been more like the Americans and prided individual liberty: Their cry was “Life, liberty and property” or “Life, liberty and the pursuit of happiness”. But the French called, “Liberté! Egalité! Fraternité!” They took it as natural that equality and fraternity were parallel values to liberty. Similarly, libertarian socialists have always taken the stance that solidarity with ones fellow man is not opposed to liberty but the essence thereof (Chomsky; Albert). People in this school view it as sociopathic to be so focused on self that one is not simultaneously focused on others, not a sign of high judgment or superior wisdom. This focus on freedom is highly Anglocentric. In any respect, it is philosophically not rigorous. Comim et al point out that it is an empirical question how useful the assumption is, since it is simply that: An assumption. They find mixed evidence that the assumption that freedom is the key metric is efficacious for research. Chomsky argues that our ideas of human nature are based entirely on intuition, and have almost no objective scientific or philosophical basis. We choose them more from hope than from reason. It is wholly possible that people are highly social animals and value equality and solidarity far more highly. It is wholly possible that people are largely tabula rasa, determined by culture, and so they will accept any level of capabilities. It is even possible that people are built to be led by individuals and so the relevant analysis is the degree of which the society rewards ambition and lionizes Ubermensch. It is a choice to put the locus of analysis, the important scale that we analyze, at the level of the individual. Why is the communitys capabilities and desires unimportant? Certainly parents are often less concerned about their “capabilities” and possibilities for their achievement than they are their childrens. One of the most serious limitations of the capability approach is that “the capability approach requires that judgments about the relative goodness of states of affairs must be based exclusively on properties of individuals. Functionings and capabilities are seen, like utility and opulence, as objects of value which individuals have-achieved or attainable effects which are disembedded from the institutional contexts of human activity. If such contexts are intrinsically valuable for individual well-being, as some communitarians argue, the capability approach is inappropriate for assessing social justice, societal well-being and development, and inequalities in individual well-being across cultures or in multicultural societies” (Gore). It is important to note that, while this idea of capabilities emerges directly from the Enlightenment, many Enlightenment philosophers were perfectly aware of the balance between individual and social goods. “Classical liberalism asserts as its major idea an opposition to all but the most restricted and minimal forms of state intervention in personal or social life. Well this conclusion is quite familiar, however the reasoning that leads to it is less familiar and, I think, a good deal more important than the conclusion itself. One of the earliest and most brilliant expositions of this position is in Wilhelm Von Humboldts "Limits of State Action", which was written in 1792, though not published for 60 or 70 years after that. In his view: "The state tends to make man an instrument to serve its arbitrary ends, overlooking his individual purposes. And, since man is in his essence a free, searching, self-perfecting being, it follows that the state is a profoundly anti-human institution” (Chomsky). As Chomsky points out, Humboldt was not a “primitive individualist” like Rousseau, and many in the Enlightenment were of a similar persuasion. Rather, Humboldt looked for a world where “social fetters” were replaced by “social bonds”. Peoples innate capabilities, the full development of their self-perfecting instinct, is inherently a social thing. Humboldt argues that “a community of free association without coercion... in which free men can create and inquire, and achieve the highest development of their power” (Chomsky). The necessity of a social focus is especially important when it comes to health care. Yes, health care is about restoring the capabilities of individuals, granting them freedom from pain and, ideally, a holistic sensation of health. But health care is inherently social. To train people to be able to heal requires a transmission of socially constructed and created knowledge. A network of universities, researchers, chemists, and factories have to transmit information and produce highly complex pharmaceutical interventions. Hospitals are immense social structures in and of themselves, and are immersed even more deeply in the structures of the community theyre part of. And with racial, gender and class inequality, health care practitioners have to be more sensitive to social issues, not less. The system of social bonds that replaces social fetters is essential to the compassion and justice of medicine. Yet another weakness of the capability approach is that it ignores the sharp distinction between political and economic rights expressed by West and Rajchman: “Economic rights... do empower people. There is a gain in dignity, autonomy and well-being, and no democrat should believe otherwise. But this must not bind one to the antipolitical consequences resulting from the preoccupation with economic rights. Unlike the situation with political rights where, for example, my possession of a right to form a voluntary association does not diminish your right to free speech, economic rights are contingent on finite resources” (pg. 250). This is somewhat exaggerated, of course. Freedom of the press depends on access to media. If I want to write in a letter to my editor, there is a finite amount of space in the Sunday paper. Similarly, sufficiently large political associations could reduce possibilities of free speech by causing social intimidation and stigma. Nonetheless, the game is not zero-sum. But with economic rights, any entitlement given to one person is by necessity taken away from another. When one adds in ecological concerns, wherein providing everyone in a society with minimal resources for survival may be all that is possible, entitlements become a truly hairy and nightmarish issue. A social goods approach at least has the advantage that its focus on things as goods gives us a focus on them economistically, so we understand that, whether the good is access to media, access to healthcare, or access to the dole, the balance sheet still zeroes out, and someone else will have to have something less. Meanwhile, the social goods approach, while initially compelling, is logically incoherent in many ways. “...[T]o develop an acceptable index of primary social goods, one will need assumptions about the comparative importance of primary and social goods... But if we can do that, why cant we tailor the requirements of social justice directly to what is required to provide” social justice in the first place (Arneson, cited in Brighouse and Robeyns)? The very advantage of the social goods approach, that one can measure social and primary goods and thus not be concerned about problems of excess atomism or value concerns, collapses. The social goods advocates are stuck between the horns of a dilemma: Either they do have the ability to measure adequately, and thus there is no need to adopt the social goods approach at all; or they cannot, and the capabilities approach, however subjective, is the only alternative left. To be fair, social goods advocates often argue much in line with market advocates: That their system is the best for limited information, not none and not unlimited. But this is a razor-thin distinction, and it still is not compelling. Markets are plagued by issues such as commodity fetishism, externalities, the undervaluing of social goods and the overvaluing of private ones, information loss, etc. (Albert). While certainly not disastrous institutions, it is absurd to say that they are the only possible decentralized system to distribute finite resources with limited information. Markets uniformly distort certain forms of information. Similarly, a social goods model, while certainly more enlightened, can similarly distort important forms of information. It might not be a social or primary good to have people feel better about themselves through plastic surgery, but economics is telling us that people are willing to expend tremendous wealth to disagree publically with this assessment. Further, there are many other logically consistent approaches one could take. I suggest at least three of these approaches as a remedy to the limitations of the social good approach Both approaches also make silly assumptions. The distinction between equality of opportunity and equality of results or outcomes is an important one, but it ultimately collapses on its own merits, for many obvious reasons. First: How can one measure opportunity without examining results or outcomes? Second: What is an equal outcome defined by? Are we looking at income? Strictly defined, equality of results as applies to income would require completely equal wages. But this would undermine equality of outcome as defines effort. Different people would be working different amounts for the same pay. This is why Albert in Parecon spends so much time focusing on remuneration for effort and sacrifice and balanced job complexes. It is meaningless to talk about results or opportunity without discussing the roles and opportunities available, and the remuneration scheme. It is perfectly true that everyone has equal opportunity to murder, batter and rob each other. But this is antithetical to any notion of justice. Similarly, it is absurd to talk about “equal opportunity” in a social system that remunerates either naked greed and bargaining power or, to a less extent, productivity. Reward for productivity seems fair, until one takes into account that people vary in terms of productivity due to different access to tools, different geographies, innate genetic characteristics, etc. Opportunity and results are largely subjective in that they are based on relative valuations. Is it equal opportunity if wages are equal but onerousness, difficulty and duration of work is sharply maldistributed? What about the opposite? Are the two situations equally bad? One could ask a hundred people and get a hundred different answers. Third: Equal opportunities in some domain demand equal results in another domain. Take insurance and estates, for example. A market cannot possibly have truly fair opportunity if people begin at different amounts of wealth irrespective of their merit. This criticism is especially important as it applies to health care. It is meaningless to talk about the positive rights of free speech when people die nearby The distinction, then, begs its own question: Which results should be held equal? Which outcomes should be distributed equally? Which opportunities should be given access to? What should be rewarded? In agrarian societies, strength is needed; in industrial societies, dexterity and intelligence. “Merit” is a social construct, and while it is a useful one, it needs to be balanced against other factors. And even our metrics are social constructs (Lewontin). Consider an Intelligence Quotient test, supposedly a test of intrinsic intelligence. Apologists for the test argue that all but a certain amount of variation in test performance is predicted genetically. But how meaningful is that? A Roman mathematician, the most brilliant of his time, with an abacus would struggle to compete with an average eighth grader with a slide rule and Arabic numerals. On the IQ test, glasses are allowed. Why is that “intrinsic intelligence?” IQ tests measure a type of intelligence useful to society. This is fair to some extent, but it is then unjust to deny people substantial wages or cause people to starve. It is in fact fairly galling that this distinction is used at all when it comes to present societies. Take an analogy Noam Chomsky has made. A foot race is being held. The winner takes home substantial money; the losers all die. Would anyone in their right mind consider this legitimate? It is certainly illegal. A libertarian might reply that losers chose to participate, but what if participation was compulsory? Then it would be elementary barbarism. The point is clear. To even discuss “equal opportunities” requires that, of the network of possible results, some not be hideously unfair or unjust. This is why Rawls created the idea of justice as fairness: If one cannot say that one would be willing to accept being a janitor, or a slave, or any other role in a social system, that social system is ipso facto unjust. Rawls philosophy in this sense is “realistic” because it recognizes that a well-functioning social system that does not create overwhelming disruption or suffering must be one that has its roles within a relative level of tolerability (Alexander, 2008). Locke and Pogges distinction about the social contract is important here. People are entitled, in this view, to whatever they could have achieved without the benefit of society. Under this view, people do not have a right to a Ferrari, but they do have a right to food and drink. Now, superficially, medical care would not fall under this category, as they could not get it innately. But people out of the social contract would also be less likely to be injured. The social contract implies a certain degree of care. The social goods approach is also hopelessly economistic. It is useful to enumerate, to the best of ones ability, relative values of goods, even taking into account the inherent subjectivity. But West and Rajchmans assertion is a double-edged sword for social goods. Recall that not everything is actually zero sum. Some political rights, the ones that would be associated with a capabilities approach, can be distributed evenly without some gaining at the cost of others. Further, even conventional economies strive to achieve a result called pareto optimality: Any gain by one requires gains for all. Both of these approaches also have the serious debit that they are utilitarian to the extreme. Both assume that societies should be spoken of in toto, even if at the locus of the individual. But is there not a right to good treatment, the justice of the society be damned? Viewing everything as a “good” or a “service” turns the richness of social experience and human life into numbers. Love is not a “service”, marriage is not a “social good”, peoples relationships, dreams and feelings can and should not be quantified. Medical practitioners take the idea that every life is infinitely precious to heart. They will do anything within their oaths to advocate for their patient. Taboos like the admonition not to violate a corpse fail when pitted against the need to save a life through organ harvesting of the dead. A social goods approach cannot tolerate an infinite. These two approaches, then, both have failures, and these failures are not complementary, so pairing them does not solve them. We need new approaches to pair with these methods and philosophies. First: Autonomy and freedom must be values that are respected above and beyond the capabilities approach and the social goods approach. The capabilities approach makes freedom a means to an end: People achieve justice when they are free. But what if they dont? What if people make horrible decisions when they are free? This is no justification for a dictator. Bakunin points out in God and State that a technocracy, a scientific ruling council based on the best understanding of the world, would be more tolerable than a benign dictatorship, a monarchy, and perhaps even more so than a dictator. But it would still be inexcusable. Similarly, he states he would rebel against God as he would against all dictators. While this is perhaps extreme, it does undermine that autonomy and freedom, both for individuals and for societies, must be taken as values and ends to themselves. Similarly, Kant points out that the Terror, no matter how vile, was infinitely more productive than the most benign of tyrannies, and that, while one should not excuse it, one should also not too quickly condemn people achieving their freedom for the first time. The maturity for freedom must be achieved by freedom itself. Children learn by making mistakes; if one were to put as a criterion for adulthood that one must make no childlike mistakes, no one would ever become adults. Without this addition, medical practitioners would never embrace informed consent. It is good for peoples capabilities if they live, their wishes be damned. It is a social good if people do not die. But a doctor who uses that reasoning to foist treatment onto a patient who does not want it is behaving irresponsibly and unethically. The capabilities approach at the least must begin with the supposition that people must be free to make their own choices as to what to pursue with their capabilities. Second, cosmopolitanism and communitarianism are also values that must be added in to both the social goods and the capabilities approach. The capabilities approach is clearly more individualistic, but isnt the social goods approach inherently social? To some extent, yes, but the locus for the social goods approach is ultimately still defined as what is good for the individual. Rawls is reasoning that it is best for the individual if society is constructed rationally. But doesnt a community have a value in and of itself? Doesnt a community need to preserve itself, to provide for its own continued survival? A social good for all the individual members of a community might be to drain a well dry and have beautiful lawns. But a social good for the community and its long-term existence is the preservation of the well. The community must be viewed as having some abstract life of its own, because in practice, its current members cannot by definition speak for all its potential members over time and space. This is why some libertarians, such as Chomsky and Albert, defend the idea of a draft. The idea that a just society, upon attack, must be able to equally distribute the cost of defending it, is a legitimate one in their view. What is the alternative? A mercenary volunteer army? Unequal distribution of who lives and dies? Medical practitioners must embrace this community ideal too. It is true that medical practitioners take the advocate of the patient as a core good. But health care educators and health care administrators logically must have a longer view. An administrator must be willing to look at a limited resource, like an organ, and distribute it based on a community approach. Could this hypothetical administrator make the decision based off of a social goods approach? Possibly, but the social goods approach could be misleading. A pure social goods analysis could have an administrator give an organ to a younger patient rather than an older one on the reasoning that the elderly patient will die first and thus will get less out of the organ. The social good is maximized. Yet the community good is not. An administrator embracing communitarianism as an additional lens, on the other hand, would consider that, while the particular older patient may get less use out of the organ, in general there is a social, communal value in preserving and respecting elders. It gives people an incentive to work hard in the present, believing that they will not be discarded to the wind in the future. It preserves the importance of wisdom and experience. The social goods analysis cannot see past the immediate calculations to a broader set of community values, norms and aspirations. It cannot quantify these less obvious factors. Further, communitarianism attunes us as medical practitioners more keenly to the disparate needs of communities. The same reasoning that leads an administrator to deny a kidney to an older patient would be the same reasoning that could lead them to deny a kidney to black patients or male patients, on the grounds that each of those groups die earlier on average. The calculus used by social goods approaches might make sense initially Take Summers famous cry for “them” to eat pollution. His reasoning was that the productivity of workers in the Third World, measured in dollars (or whatever other currency), is lower, so the economy is hurt less by their pollution. Luckily, a capabilities approach would reject this as repellent since it denies the equal capability of those people to exercise their rights and intellect. But under a social goods approach, this reasoning could be grudgingly accepted; indeed, Summers used this reasoning to try to browbeat his critics into agreeing! Both of these approaches get it wrong. The reason this is repellent is because those people have rights not to be polluted upon for things they did not purchase, for the benefit of others, no matter how “efficient” it might be under some arbitrary definition. Indeed, both of these approaches may represent justice in some way, but they assume that the conditions preceding the calculations were themselves just. If goods are valued differently because of unjust past, then these approaches both fail. Finally, I propose the addition of a eudaemonic understanding. Aristotles eudaemonia was a general community sense of well-being and good, achieved by rational exploration of enlightened self-interest (Kraut, 2010). Aristotle recognized that people were perfectly capable of being apparently happy while doing horrible things. He recognized that happiness, on its own, is not a sufficient virtue. Rather, one has to understand a type of happiness that is based in long-term, sustainable, moral understanding. For Aristotle, as for the Buddha and for the Dalai Lama, once illusion and misconception is waived away, the distinction between the good, the virtuous, and the happy is arbitrary. Kraut argues that, without a eudaemonic understanding, a broader understanding of good and happiness, we make terrible decisions. This is why we do not prescribe opiates to patients so they can spend the rest of their life in a drug-induced haze, despite the fact that, with enough opiates to last a lifetime, a patient would not suffer too terribly. Putting aside practical concerns, doing so would be hideously irresponsible because a drug-induced haze, while it might be happiness of a sort, is not eudaemonic. It is a happiness that blunts the mind rather than ascends it, that deprives the victim of it to isolation rather than connection to a community. Eudaemonia is an alternate metric. Once we have corrected for communitarianism, unjust starting conditions, and autonomy and freedom, a eudaemonic addition allows us to properly measure social goods and properly measure the capabilities people must exercise to become truly virtuous and well-functioning. Neither social goods analyses nor capabilities analyses are themselves bad concepts, and their advocates are perfectly sincere, well-meaning and insightful. But no one theory is going to guide us very well in social affairs where we know so little. Medical practitioners must use many different approaches: At the least, they must combine social goods, autonomy, freedom, capabilities, eudaemonic metrics and correction for unjust starting conditions. Works Cited Albert, Michael. Parecon. 2004. Alexander, John. Capabilities and social justice: the political philosophy of Amartya Sen and Martha Nussbaum. Ashgate Publishing. 2008. Brighouse, Harry and Robeyns, Ingrid. Measuring Justice. Cambridge University Press. 2010. Chomsky, Noam. Chomsky on Anarchism. AK Press. 2005. Comim, Flavio; Mozaffar, Qizilbash; and Alkire, Sabina. The capability approach: concepts, measures and applications. Cambridge University Press, 2008. Daniels, Norman. Just Health. Gore, Charles. Irreducibly social goods and the informational basis of Amartya Sens capability approach. Journal of International Development. 1997. His Holiness the Dalai Lama. Ethics for the New Millennium. Kraut, Richard. Aristotles Ethics. May 1, 2001. Revised March 29, 2010. Stanford Encyclopedia of Philosophy. Mathis, Rick. Health Care And Philosophy: Adding Justice To The Debate. Health Affairs, 26, no.1 (2007):291-292. doi: 10.1377/hlthaff.26.1.291 Rajchman, John and West, Cornel. Post-analytic philosophy. Columbia University Press. 1985. Rawls, John (Erin Kelly ed.). Justice as fairness: a restatement. Harvard University Press. 2001. Raz, John. Morality of Freedom. Read More