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Insulin and American Healthcare

photograph of blood sugar recording paraphanelia

On March 31st the Affordable Insulin Now Act was passed by the House and is now being considered by the Senate. The House bill only applies to people who already have insurance, and caps the out-of-pocket costs for insulin to 35 dollars per-month. It does not address the uninsured, nor does it directly address the retail price of the drug. For advocates, it stands as a limited but hopefully effective response to the surging cost of life-saving insulin in the U.S., the crucial medicine for the management of diabetes.

Sponsoring congresswoman Angie Craig (D) of Minnesota stated:

Certainly our work to lower drug costs and expand access to healthcare across this nation is not done, but this is a major step forward in the right direction and a chance to make good on our promises to the American people.

It is also true to the original promise of insulin.

Isolated in 1921, the firsts patents for insulin were sold to the University of Toronto for the price of one dollar as part of a defensive maneuver to ensure insulin could be produced widely and affordably. Nonetheless, insulin became a goldmine. Cheap to manufacture and widely used, it could bring home a tidy profit even at low prices. Since the early days, three pharmaceutical companies, American Eli Lilly, French Sanofi, and Danish Novo Nordisk, have produced the vast majority of global insulin and captured almost the entire U.S. market. Low production costs continue, but insulin is no longer sold at low prices. At least not in the U.S. Eli Lilly’s popular Humalog insulin is sold to wholesalers at 274.70 per vial, compared to 21 dollars when first introduced in 1996. Further costs accrue as insulin makes its way through the thicket of wholesalers, pharmacy benefits managers, and pharmacies before reaching customers.

One question that emerges from the whole mess is: Who is to blame for this development? Here, blame needs to be understood in two senses. The first concerns all those actors who are partly causally responsible such that if they had behaved differently, the price of insulin would not be so high. American healthcare economics is ludicrously complex, and a discussion of the price of insulin quickly blossoms into biologics and biosimilars, generics, pricing power, patents, insurance, the FDA, pharmaceutical benefit managers, and prescription practices. What idiosyncrasies of the American healthcare systems allow a drug price to increase 1000% without being undercut by competition or stopped by the government? Insulin is not the only example.

But there is a second sense of blame, and that is which actors most directly chose to increase the costs of a life-saving medicine and thus are potentially deserving of moral opprobrium.

The big three manufacturers, with their overwhelming market share and aggressive pricing strategies are clear targets. However, when investigated by the Senate in 2019, they pointed fingers at pharmacy benefit managers. These companies serve as intermediaries between manufacturers and health insurance companies. Like insulin manufacturers, the pharmacy benefit manager market is highly consolidated, with only three major players: CVS Caremark, Express Scripts, OptumRX. They can benefit directly from higher manufacturer prices by raking in fees or rebates. While noting that only Eli Lilly and CVS Caremark fully responded to requests for documents, the Senate investigation found problematic tactics on the part of both pharmacy benefit managers and manufacturers, such as leveraging market power and raising prices in lockstep.

The bill, it should be noted, is most directly targeted at insurance companies, rather than these other actors. This leads to both an economic and an ethical objection. The economic objection is that by forcing insurance companies to cap prices and absorb the cost of insulin, the insurance companies may simply turn around and raise premiums to recoup profit. The ethical objection is that it is unfair for the government to intercede and force costs of say, aggressive pricing by the manufacturer, onto some other party. The caveat to the ethical objection is that each of the three major pharmaceutical benefits managers have merged with major insurance companies.

What are the business ethics of this all? One approach would be stakeholder theory, which holds that corporate responsibility needs to balance the interests of multiple stakeholders including employees, shareholders, and customers. Pricing a medically-necessary drug out of the range of some customers would presumably be a non-starter from a stakeholder perspective, or at least extremely contentious.

The more permissive approach would be the Friedman doctrine. Developed by the economist Milton Friedman, it argues that the only ethical responsibility of companies is to act in the interest of their shareholders within the rules of the game. This is, unsurprisingly, controversial. Friedman took it as all but axiomatic that the shareholder’s interest is to make as much money as possible as quickly as possible, but the choice is rarely put bluntly: “Would you, as a shareholder, be okay with slighter lower profit margins, if it meant more diabetics would have access to their insulin?” (For Friedman this moral conundrum is not supposed to occur, as his operating assumption is that the best way to achieve collective welfare is through individuals or firms chasing their own interests in the free market.)

Separate from questions of blame and business ethics are the grounds for government intervention in insulin prices. Two approaches stand as most interesting and come at the problem from very different directions. The first is a right to healthcare. Healthcare is what is sometimes referred to as a positive right, which consists of an entitlement to certain resources. There is as yet no formal legal right to healthcare in the United States, but Democratic lawmakers increasingly speak in this framework. Obama contended, “healthcare is not a privilege to the fortunate few, it is a right.” Different ethicists justify the right to healthcare in different ways. For example, Norman Daniels has influentially argued that a right to healthcare serves to preserve meaningful equality of opportunity by shielding us from the caprice of illness. A slightly narrower position would be that the government has a compelling interest in promoting healthcare, even if it does not reach the level of a right.

A completely different ground for intervention would be maintaining fair markets. This gets us to a fascinating split in reactions to insulin prices. Either there is too much free market, or not enough. Advocates of free markets criticize the regulatory landscape that makes it difficult for generic competitors to enter the market, or the use of incremental changes to insulin of contested clinical relevance to maintain drug patents in a practice called “evergreening.”

The “free market” is central to the modern American discussion of healthcare, as it allows considerations of healthcare to not be discussed in terms of rights – that everyone deserves a right to healthcare – but in terms of economics. Republican politicians do not argue that people do not deserve healthcare, but rather that programs like Medicare for All are not good ways to provide it.

At the center of this debate, however, is an ambiguity in the term free market. On the one hand, a free market describes an idealized economic system with certain features such as low barriers to entry, voluntary trade, and prices responding in accordance to supply and demand. This is the use of free markets found in introductory textbooks like Gregory Mankiw’s Principles of Macroeconomics. This understanding of a free market is at best a regulative ideal, in that we can aim at it but we can never actually achieve it and all actual markets will depart from the theoretical free market to some degree or another.

On the other hand, the free market is used to refer to a market free from regulations and interference, especially government regulations, although this understanding does not follow from the theoretical conceptualization of the free market. Oftentimes government interference – such as breaking up an oligopoly – is precisely what is needed to move an actual market towards a theoretical free market. Even for advocates of free market economics, interventions and regulations should be evaluated based on their effect, not based on their status as interventions. From this perspective, the current insulin price represents not an ethical failure but a market failure and justifies intervention on those grounds.

The current bill, however, does not try to correct the market, but instead represents a more direct attempt to secure insulin prices (for people with insurance). This is an encouraging development for those who believe essential goods like insulin should not be subject to the whims of the market. More discouragingly, the bill is likely dead in the Senate.

Underrepresentation in Clinical Trials and COVID-19

photograph of vaccine waiting line

There have long been concerns about underrepresentation in the clinical trials of medical products, and there has been a large push for the testing of COVID-19 vaccines to be more inclusive due to the urgency of the problem and danger the virus poses to all of us. The current situation presents an opportunity to assess the previous model that tended to emphasize efficiency — doing the most good for the most amount of people as quickly as possible, often in the interests of speeding production — at the cost to underrepresented groups continually having to use medical products not specifically designed for them.

Historically, both medical professionals and clinical trial participants were primarily men. Making up more than half of the population, women were drastically underrepresented in medicine. This underrepresentation resulted in vast differences in healthcare for men and women. This is important because men and women present different symptoms of disease. Since men have largely been the sample for clinical trials of medical products, there is far more medical knowledge about how men present symptoms of various diseases. This makes diagnosis for women more difficult, and it makes their symptoms seem abnormal.

The underrepresentation of women in clinical trials also impacts the treatment of diseases. When male cells, male animals, and men are the basis of clinical trials, researchers are looking only at the effects on one-half of the population. Often, when women were included in these trials, their data was not analyzed separately or significantly, so differences in experiences were not addressed. After trials, women would take medicine that had not been optimized for them, which could result in negative health consequences. For example, Ambien, a sleep aid, was not tested for differences in effects on men and women. When Ambien became available for use, the slower metabolism of women meant that the drug stayed in their systems longer than men, so the dose was too high for women.

One reason for the low representation of women in clinical trials is that researchers worried that women’s reproductive cycles and hormones would overcomplicate the study and provide confounding variables. However, these variables are part of the reason why men and women both need to be included in clinical trials. When hormonal fluctuations and reproductive cycles are not taken into account, it is uncertain exactly how a medical product will work.

Another reason women were often excluded from clinical trials was fear of harming fertility. In 1977, the FDA recommended  women of childbearing age do not participate in clinical trials for fear that medical products may harm a fetus in the event that the woman became pregnant. This recommendation was put into place after exposure to some drugs caused birth defects. In the past, little research was done about women’s health that did not relate to reproductive health. Fertility seemed to be the primary concern about women’s health, so it was treated as more important than the potential benefits of including women in clinical trials.

The FDA reversed this recommendation in 1993 over ethical concerns about prioritizing the fetus over the potential benefits of including women in clinical trials. The recommendation’s reversal was also related to concerns about autonomy. When the FDA put forth the recommendation, they made it significantly more difficult for women who wanted to participate in clinical trials to do so. Despite some women not wanting children or simply valuing the advancement of women’s health more than any potential negative health effects they may face, women were excluded from trials. The FDA attempted to address safety concerns, but ultimately changed their recommendation because of the constraints on personal choice. While there remain safety concerns, women can now choose to participate in clinical trials.

Due to the urgent nature of the pandemic, ensuring that the vaccine is viable for as many people as possible is a priority. To achieve this, clinical trials have been more inclusive of many medically underrepresented groups, such as pregnant women, minorities, and people with certain medical conditions. Pregnant women can choose to participate in the clinical trials for the vaccine far earlier than they are able to for most medical products. This is partly due to the funding for vaccine development and the higher risk that pregnant women face with COVID-19.

In the future, it is uncertain whether medically underrepresented groups will continue to have the same participation they currently enjoy. While it is clear that these groups ought to have more representation in clinical trials, some medical professionals have concerns about funding and time. Most medical products do not have the funding that the COVID-19 vaccine has. Lower funding limits the number of people who can participate in a clinical trial. Additionally, there are time constraints. When a medical product is necessary, it is important that it is released as soon as possible. Knowledge of the potential health risks for different groups must be weighed with the benefits of releasing the medical product as soon as possible. Often, this means that the human trials consist of healthy men and women with no other conditions being the primary subjects. Later, the effects for individuals with various health conditions may be tested as well, but this is rarely made a priority.

The history of discrimination in clinical trials forces us to consider whether efficiency in the production of a medical product designed for the greatest number of people is truly fair when it means that persistently underrepresented groups continue to suffer from a lack of viable medical products tailored to their particular needs.

U-Haul’s Anti-Smoking Workplace Wellness

photograph of overcrowded UHaul rental lot

This article has a set of discussion questions tailored for classroom use. Click here to download them. To see a full list of articles with discussion questions and other resources, visit our “Educational Resources” page.

U-Haul International recently announced that, beginning next month, the company will not hire anyone who uses nicotine products (including smoking cessation products like nicotine gum or patches). The new rule will take effect in the 21 states that do not have smoker protection laws. The terms of employment will require new hires to submit to nicotine screenings, placing limits on employees’ lawful, off-duty conduct.

The truck and trailer rental company has defended the new policy as nothing more than a wellness initiative. U-Haul executive Jessica Lopez has described the new policy as “a responsible step in fostering a culture of wellness at U-Haul, with the goal of helping our Team Members on their health journey.” But as the LA Times points out, “Simply barring people from working at the company doesn’t actually improve anyone’s health.”

U-Haul, however, is not alone, and employer bans on smoking are not new. Alaska Airlines has had a similar policy since 1985, and many hospitals have had nicotine-free hiring policies for over a decade. But there are important distinctions between these past policies and U-Haul’s new policy. Alaska Airlines’ ban was, at least in part, justified by the risk and difficulty of smoking on planes and in places surrounding airports; smoking simply isn’t conducive to that particular work environment. Meanwhile, hospitals’ change in hiring process was meant to support the healthy image they were trying to promote, and to demonstrate their commitment to patient health.

Interestingly (and importantly), U-Haul has not defended its new policy as a measure to improve customer experience or improve employees’ job performance. The (expressed) motivation has centered on corporate paternalism – U-Haul’s policy intends to protect their (prospective) employees’ best interests against their employees’ expressed preferences – and this has significant implications. This isn’t like screening for illicit drugs or forbidding drinking on the job. As Professor Harris Freeman notes, it “makes sense to make sure people are not intoxicated while working … there can be problems with safety, problems with productivity.” But in prohibiting nicotine use, U-Haul “seems like they’re making a decision that doesn’t directly affect someone’s work performance.” Unlike Alaska Airlines or Cleveland Clinic,

“This is employers exercising a wide latitude of discretion and control over workers’ lives that have nothing to do with their own business interests. Absent some kind of rationale by the employer that certain kind of drug use impacts job performance, the idea of telling people that they can’t take a job because they use nicotine is unduly intrusive into the personal affairs of workers.”

Similarly, the ACLU has argued that hiring policies like these amount to “lifestyle discrimination” and represent an invasion of privacy whereby “employers are using the power of the paycheck to tell their employees what they can and cannot do in the privacy of their own homes.” This worry is further compounded by the fact that,

“Virtually every lifestyle choice we make has some health-related consequence. Where do we draw the line as to what an employer can regulate? Should an employer be able to forbid an employee from going skiing? or riding a bicycle? or sunbathing on a Saturday afternoon? All of these activities entail a health risk. The real issue here is the right of individuals to lead the lives they choose. It is very important that we preserve the distinction between company time and the sanctity of an employee’s private life. Employers should not be permitted to regulate our lives 24 hours a day, seven days a week.”

Nicotine-free hiring policies or practices that levy surcharges on employees who smoke tend to rely heavily on the notion of individual responsibility: employees should be held accountable for the financial burden that their personal choices and behaviors place on their employers and fellow employees. But these convictions seem to ignore the fact that smoking is highly addictive, and 88% of smokers formed these habits before they were 18. Given this, the issue of accountability cannot be concluded so cleanly.

Apart from concerns of privacy or questions about individual responsibility, smoking bans on employment present a problem for equality of opportunity. According to the CDC, about 14 percent of adults in the U.S. smoke cigarettes. But smokers are not evenly distributed across socioeconomic and racial groups. For instance, half of unemployed people smoke; 42% of American Indian or Alaska Native adults smoke, 32% of adults with less than a high school education smoke; and 36% of of Americans living below the federal poverty line are smokers. It’s not hard to see that nicotine-free hiring practices disproportionately burden vulnerable populations who are already greatly disadvantaged. U-Haul’s low-wage, physical labor jobs, from maintenance workers to truck drivers to janitors, are restricted from those who may need them most (on grounds that have nothing to do with a candidate’s ability to perform job-related tasks).

This is no small thing; the Phoenix-based moving-equipment and storage-unit company employs roughly 4,000 people in Arizona and 30,000 across the U.S. and Canada. Lopez has claimed that “Taking care of our team members is the primary focus and goal” and that decreasing healthcare costs is merely “a bonus,” but it’s hard to separate the two. A recent study by Ohio State University estimated the cost employees who smoke pose to employers. Added insurance costs as well as the productivity lost to smoke breaks and increased sick time amounted to nearly $6,000 annually. Clearly, employee health, insurance costs, and worker output are all linked, and all contribute directly to a company’s profitability. The question is who should have to pay the cost for the most preventable cause of cancer and lung disease: employers or employees?

It may be that the real villain here is employer-sponsored insurance. By decoupling one’s employment from one’s healthcare, companies like U-Haul might be less invested in meddling with their employees’ off-duty choices. They have much less skin in the game if their employees’ behaviors aren’t so intimately tied to the company’s bottom line. Unless healthcare in the US changes, we may be destined to constantly police the line separating our private lives from our day jobs.

Life, Death, and Aging: Debating Radical Life Extension

photograph of grandmother and grandson under blankets with a book laid down

An article from The Atlantic has resurfaced in the last week, sparking new discussions about the impact of healthcare on our end of life desires and decision-making. In 2014, Ezekiel J. Emmanuel articulated his reasons for wanting to die at 75 in a provocative op-ed. In 2019, he confirmed that his position has not changed. Emmanuel’s worry is that,

It renders many of us, if not disabled, then faltering and declining, a state that may not be worse than death but is nonetheless deprived. It robs us of our creativity and ability to contribute to work, society, the world. It transforms how people experience us, relate to us, and, most important, remember us. We are no longer remembered as vibrant and engaged but as feeble, ineffectual, even pathetic.

When polled in 2016, over half of people in the U.S. would not want to adopt enhancements that would enable them to live longer, more healthy lives. While 68% of those polled responded that they thought “most people” would “want medical treatments that slow the aging process and allow the average person to live decades longer, to at least 120 years,” only 38% of respondents said that they personally would want such treatments. In this same poll, 69% were almost in agreement with Emmanuel, that their ideal lifespan would be 79-100 years (only 14% said 78 or younger, and Emmanuel is actually in this small camp). There are many considerations that go into this preference.

One motivation against life extension is thinking that we are only deserving some natural amount of time on this earth, perhaps in order to fulfill a religious or spiritual commitment to “move on.” Over half of the respondents in the Pew survey considered treatments that extend life to be “fundamentally unnatural.” The distinction in bioethics between “treatment” and “enhancement” could be playing a significant role here; it is easy to justify intervention to make someone whole, to restore or to ensure a state of health. Such interventions are deemed “treatment,” and are more easily covered by insurance in the U.S. “Enhancements,” on the other hand, make one better than well, or do not have wellness as an aim. Of course, there are gray areas in medical interventions that don’t fit neatly into one or the other of these categories. Obstetrics, for example, doesn’t aim to treat an illness, but nor does it seek to “enhance” the future parent.

For many, considering a life without an end point is disorienting in the extreme. Philosophers from Martin Heidegger to Bernard Williams were committed to the idea that death – a final conclusion – is necessary for bringing meaning to life. If life’s meaning is similar to the meaning that a story’s narrative has, then we may think of it as consisting of stages, with different stages shaping the import and significance of the events that came before. If a life were to go on indefinitely, it could undermine the ability to shape a narrative or derive purpose in each stage. Radically or indefinitely delaying the conclusion can be seen to thus diminish or undermine the meaning in one’s life.

For many, the considerations against life extension are grounded less in theory and more in practice. If lives are indefinitely extended, this will increase the elderly population. The potential additional strain on environmental and social resources of the additional population could be cause for concern (a la Malthus). The impact on the economy, if living a longer life means staying in the workforce longer, could mean that young people have a harder time entering the workforce when competing with workers that have decades of experience. If those who extend their lives do not remain in the workforce, then different social pressures would arise – supporting a booming retired population, for instance. Regardless of the labor considerations, an extended lifespan could alter the shape and meaning of relationships. Marriages that previously consisted of a commitment of less than 50 years now may seem like unrealistic arrangements if people can anticipate living another 50 years past the average lifespan today.

Further, the practical considerations for and against radical life extension are enmeshed in our current understandings of health care, aging, and dependence. Our worries of becoming a burden to our loved ones should our health conditions require some degree of dependent living is contingent on governmental structures not providing support, either directly to those living with conditions of dependence or to those who will care for them. The way we consider the connection between dependence and burdening is also wrapped up in the way we value IN-dependence.

In the end, the theoretical question regarding the morality of extending the average human lifespan is inextricably tied to the realities of the social and political systems in which we live.

Some Hospitals Sue Their Delinquent Patients. Should They?

photograph of coin jar spilling out on top of medical bills

Despite the passing of the Patient Protection and Affordable Care Act — i.e., Obamacare — in 2010, health care reform remains a contentious political issue. Costly procedures and huge medical bills still pose insurmountable financial burdens for many Americans — even those who are insured; thus, the appetite to ameliorate the pain remains. As reported in a recent CNBC article, a recent study concluded that 66.5% of all bankruptcies were related to medical issues. Whatever the positive effects of health insurance reform have been, it has not provided full protection for people from the threat of financial ruin because of unpaid medical bills.

Are there policies that healthcare systems and hospitals have instituted that may be exacerbating this problem? Indeed. Some hospitals will sue their patients for these unpaid medical bills, thus subjecting some patients to the additional expenses and stresses of navigating the legal system. Now, not all hospitals do this, and some hospitals sue their patients much more than others. A recent NPR article covered a study published in The Journal of the American Medical Association (JAMA) that showed that 36% of hospitals in Virginia sued patients and garnished wages in 2017. What’s more, just 5 hospitals accounted for more than half of the lawsuits, and all but one of these hospitals were non-profit institutions. As such, it is important to recognize this as a choice made by certain hospitals, rather than a widely accepted and unavoidable practice. In fact, hospitals have other choices to make regarding unpaid debts. These debts could be passed to collection agencies or written off as “bad debt.”

Hospitals, of course, face financial pressures of their own, and suing and garnishing to recoup unpaid medical debt is one strategy for easing these pressures. Hospitals defend the practice as both legal and transparent. Detractors claim that the practice violates the ethos of hospitals, understood as institutions that exist for the community benefit. We can approach the underlying divide in this debate in terms of whether healthcare is morally special. If health care is not special — if it is a normal consumer good just like other consumer goods — then it is fitting and proper to treat trade in healthcare goods as subject to contract law, where the courts play a vital role in ensuring fairness in economic relations. On the other hand, if health care is morally special — if it is not just like other consumer goods because it has some essential connection to the concerns of justice — then different rules governing economic conflicts in the exchange of health care goods ought to apply.

Presume that we are treat healthcare like any other good. By receiving healthcare services, customers implicitly agree to pay for them. By refusing to pay, they have broken this implicit contract. The courts exist as a transparent, politically legitimate, and unbiased enforcer of these contracts, ensuring that what debts have legally and properly been incurred do get paid. If service providers are not given the public assurance that they will be paid for the services they provide, then they would have to take on the extra risk of either losing out on payments or the extra burden of trying to collect on their own. Hospitals, thus, have a legal right to sue their patients, and it is fitting that they do.

If healthcare is a different kind of good — if healthcare is considered somehow special — then the above standard analysis of why service providers ought to have a right to sue no longer applies so neatly. Two observations can be made to suggest healthcare ought to be treated as special. First, healthcare exists to protect, maintain, and enhance a person’s health. Though through most of human history, our abilities to significantly affect the course of diseases had been limited, technological and social advances of the 20th and 21st century have produced a healthcare system that indeed can prolong the length and enhance the quality of lives. Having a life, of course, is a precondition of living a good life. Sickness and premature death limit the opportunities of living a life according to one’s life-plan. If justice entails the principal that society ought to foster equal opportunity, then healthcare has special moral significance because of its connection to health and, therefore, life opportunities. This is the basic argument made by Norman Daniels in his 1985 book Just Health Care.

Healthcare’s special status may also be rooted in vulnerability. The instinctive value we place on protecting our own health and well-being makes us vulnerable to exploitation when our health is threatened. The standard model outlined above presumes that the consumer will act rationally and take into consideration things like price and need when purchasing a product. And yet for the need of prolonging one’s own life and health, there is often no price we wouldn’t accept. This is not to say that reforms to the healthcare system that would force hospitals to be more transparent about price wouldn’t be a welcome change. Rather, I doubt that this change alone would significantly protect patients’ vulnerability to exploitation on this matter.

Considering these observations, one may argue, healthcare should be given a special status, and standard norms of contract law ought not to define the rights and responsibilities of providers in attempting to collect on medical debts. If we follow this line of argument, we are still stuck with the obvious rejoinder that providers deserve to be compensated for their vital labor. We should not expect them to work for free. I think this quite quickly pushes us down the path of envisioning publicly funded schemes to finance health care, whether that be a single-payer model or some other mixed system. If healthcare’s moral importance undercuts the private rights of economic actors in the healthcare market, then public obligations ought to step in to ensure a scheme that distributes care to those in need and adequately compensates the caregivers central to the system.

Does Care Require Personhood? The Ethics of Robot Caregiving

Smiling caregiver embracing happy senior woman in nursing home

Emerging technologies have presented people that require daily medical services with a wider range of options. For example, Rudy the healthcare robot can be purchased by a patient for $5,000 or leased for $100 a day. Though these numbers may seem high, the average cost of at-home medical care provided by a human caregiver is $4,099 a month. Rudy offers care at a significantly lower cost. Rudy can perform a wide range of tasks including wound care, ostomy care, and the administration of injections. Often, patients simply need assistance getting out of bed to use the restroom at night, and as round-the-clock medical assistance is particularly expensive, Rudy can be there for the basic nighttime needs of patients at a fraction of the cost.

For people who suffer from depression, anxiety, or related mental health challenges, there is PARO, the robotic therapy seal. In a promotional video for PARO, a research scientist makes the remarkable claim that “PARO has a value system that includes enjoying being stroked and disliking being hit.” The personality of the seal is determined by what its owner likes. When the seal is stroked, the behavior that preceded the stroke will be reinforced, and the seal will engage in that behavior more frequently. As a result, the patient can guarantee that the robotic seal will exhibit behavior that they find soothing or uplifting. The psychological results are similar to the results produced by therapy animals, but without the uncertainty that comes along with the spontaneous behavior of a living creature. The robot is particularly effective in providing psychological relief to patients with dementia.

Relatedly, Same Day Security recently raised 35 million dollars for its Addison project. Addison is a virtual healthcare companion who appears on ten-inch screens strategically placed around one’s home, asking patients regularly about whether they’ve taken their medication, exercised, or consumed healthy meals. Addison can detect motion and can guide patients through exercise routines. Addison can also track vital statistics and keeps records of those statistics to share with the patient’s doctor, should the patient choose to do so.

For a number of reasons, these technologies appear to many to be a step in the right direction. Many sick people who require frequent care don’t have family members that can reliably provide that care, and the cost of personalized care can be quite steep. But it’s more than simply a matter of cost. Medical procedures involve the care of bodies and a person’s body is something over which they frequently want to retain some privacy. These procedures are very personal procedures, and the involvement of another human being can sometimes be quite jarring and even humiliating. Each of these potential solutions – Rudy, PARO, and Addison – is incapable of taking the kinds of attitudes toward human bodies that a patient might fear. If a patient is humiliated in the presence of a robot caregiver, they’ve made a category mistake.

Another benefit of robotic and virtual technology when it comes to healthcare is that robots won’t be affected by the stress inherent to the healthcare system. Even the most professional human healthcare providers can respond poorly to the difficulties posed by ill health. Understandably, patients aren’t always capable of responding to their medical problems with good humor, and this can be difficult to navigate for a human caregiver. Robot caregivers are in a better position when these difficulties arise.

In cases in which a patient cannot afford a professional caregiver, the responsibility often falls to family members. If a patient is elderly, their children frequently step in to provide the care. These adult children often have careers and families of their own, and the new responsibility of providing care for an ailing parent can be a significant stressor. What’s more, this burden tends to fall disproportionately on the shoulders of the patient’s female children. When career and other personal sacrifices need to be made to make time for caregiving, it is more often females who make those sacrifices. Robot caregivers provide a potential solution for everyone, and help to lessen the disproportionate burden placed on women.

These new trends in healthcare technology might be useful for other reasons. Many countries, like China, have rapidly aging populations. By the middle of this century, 450 million people in China will be over the age of 65. There simply aren’t enough caregivers to satisfy the needs of all elderly patients. This trend is exacerbated by people having fewer children in order to reduce carbon emissions. When populations start having fewer children, they also ultimately have fewer young people to provide care as older generations age. Robot caregivers can potentially solve this problem.

Others are not so impressed with this technology. They argue that care relationships are, fundamentally, relationships between persons. While PARO, Addison, and Rudy provide services for patients, they aren’t actually providing care for patients. Care requires attentiveness to needs and a genuine willingness to satisfy those needs for the good of the person in need. We are falling short of our duty to patients if we provide them, merely, with service, when every person is deserving of care.  

It may well be the case that these technologies are less expensive for patients, and that’s important. But the fact that robot care is less expensive might be viewed as an indictment of our health care system rather than an argument in favor of a robotic solution. Perhaps instead we should support elected officials who plan to pass legislation to make health care affordable for everyone. We could lessen the burden on family members by creating a system in which real human professionals were affordably available to anyone in need of their services.

For patients who desire increased privacy, robotic health care could continue to be an option. It shouldn’t be the case, however, that patients are essentially coerced into choosing a less intimate form of care simply because they cannot afford the alternative.

The Ban on Trans Service Members and Injustice of Healthcare Cost Disparities

close-up photograph of the boots of four servicepeople

President Trump has banned trans members of the military from openly serving and from joining up. The reasoning behind the ban is that inclusion would result in higher medical costs and lower troop cohesion. On January 22nd, SCOTUS lifted an injunction on enacting the ban, and lower courts will proceed with evaluating the ban while the military will be more free to follow it.

As a Vox report articulates, there are multiple dimensions along which this ban is offensive: “Trump’s ban could lead to some very ugly consequences: trans service members staying in the closet, even when it’s dangerous for their service and their personal health and safety; trans troops being discharged or abused; and trans Americans more broadly receiving yet another signal that society still doesn’t accept or tolerate them.”

Besides issues of discriminatory injustice, this ban has significant practical effects: over 134,000 American veterans are transgender, and over 15,000 trans people are serving in military today. The US has been at war for decades, so it is unclear why barring willing people from serving would be a wise strategy, especially for this demographic, as it’s been reported that “twenty percent of transgender people have served in the military, which is double the percentage of the U.S. general population that has served.”

The most suggestive support for the ban comes from research from the RAND Corporation which indicates that including openly serving trans folk in the military would make up “a 0.04- to 0.13-percent increase in active-component health care expenditures.” However, research from countries that allow openly serving in the military according to your gender identity, including the UK, Israel, and Canada, suggests that there is no cost to military preparedness or problems with the military’s budget.

The supposed extra cost of healthcare has been used as a tool of discriminatory practices both inside and outside of the military. Before Obamacare, it was allowable practice for women’s health insurance to be more costly than men’s, for instance. Even harsh critics of the law admit, “The Affordable Care Act enacted pricing rules that largely prohibited charging women higher health-insurance premiums than men, and the Republican plan would relax some of those restrictions, which probably would result in women’s paying higher premiums.”

Debates over whether being a woman should play the role of a “preexisting condition” bring to light the way healthcare should be conceived of and distributed. It is true that women pay more over their lifetime for healthcare than men, on average, despite, again on average, taking better care of themselves.

Health is a human good that is unevenly distributed by a natural lottery – both at birth with conditions that make health needs vary and later in life in the form of health-altering events such as accidents and disease. That some individuals may need more assistance in order to maintain health does not undermine its status as a fundamental human good.

There isn’t evidence that being trans interferes in any way with one’s ability to serve in the military – the inclusive policies of other nations serve as evidence to the contrary. The proposed ban on openly trans military service member is thus at best a matter of medical discrimination, but that justification is thin, given the diverse medical needs of diverse populations. In reality the ban is a barely veiled instance of putting transphobia into policy.

Questions on the Ethics of Triage, Posed by a Sub-Saharan Ant

an image of an anthill

This article has a set of discussion questions tailored for classroom use. Click here to download them. To see a full list of articles with discussion questions and other resources, visit our “Educational Resources” page.

In a new study published in Proceedings of the Royal Society B, behavioral ecologist Erik Frank at the University of Lausanne in Switzerland and his colleagues discuss their findings that a species of sub-Saharan ants bring their wounded hive-mates back to the colony after a termite hunt. This practice of not leaving wounded ants behind is noteworthy on its own, but Frank and fellow behavioral ecologists note that the Matabele ants (Megaponera analis) engage in triage judgments to determine which injured ants are worth or possible to save–not all living wounded are brought back to the nest for treatment.

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Should Conscientious Objections Apply to Healthcare?

An image of a surgeon operating on a patient.

While executive orders and high-profile legislation garner the most media coverage, much of the change that comes with a new presidential administration happens in the individual departments staffed by new political appointees. The current administration has pushed far-reaching changes regarding the place of religious belief in the healthcare system through actions at the Health and Human Services Department. I’ve previously covered the administration’s decision in October 2017 to widen the scope of exemptions to the contraception mandate. More recently, NPR reported that the Department of Health and Human Services is opening a new Division of Conscience and Religious Freedom to defend health care workers who object to participating in medical care for patients because of their sincerely held religious beliefs. Notably, the establishment of the division also reverses an Obama-era rule barring “health care workers from refusing to treat transgender individuals or people who have had or are seeking abortions.”

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Untangling the “Sincerely Held Moral or Religious Belief”

A photo of Donald Trump and Mike Pence leaving Air Force One

On February 10, 2012, the Obama Administration announced that the preventive care benefits mandated by the Patient Protection and Affordable Care Act (aka “Obamacare”) would be interpreted to include contraception coverage. This decision proved controversial from the very beginning and elicited numerous legal objections. Many religious organizations and religious owners of businesses objected to the narrow scope of religious exemptions originally allowed in the mandate. Notably, the Supreme Court ruled in 2014 to expand the exemptions to the mandate to include closely held for-profit corporations with “sincerely held religious beliefs.” At issue in these legal challenges was whether the contraception mandate substantially burdened the free exercise of religion, as it is protected under the First Amendment to the US Constitution and the Religious Freedom Restoration Act.

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Less Healthcare, Less Regulation: Is Donald Trump Killing People?

A photo of a woman in a hospital bed

Follow liberals and anti-Trump conservatives on Twitter and you will often see the accusation that Donald Trump is killing people. For example, here are some recent tweets from three Trump critics:

Pepin Lachance @PepinLachance: @foxand friends @realDonaldTrump GOP and Trump undermining the healthcare of US citizens. They should be ashamed. People will die due to republicans they are killing us.  

Gia Sonata @RedGia: @GeorgeTakei @sherrilee7 Oh – Trump is killing people.  Slowly.  With TrumpCare.  Deregulation. FLINT still doesn’t have clean water.  “Killing me softly w/his song”

Josh B @joshious: @SenDeanHeller @BillCassidy @LindseyGrahamSC Nevadans will hold you accountable for killing thousands of people and raising healthcare costs for all if you don’t vote NO on Trumpcare!

Repealing Obamacare would certainly lead to deaths.  Twenty to 30 million people would lose their health insurance under the various repeal-and-replace bills that were considered by Congress in July.  Loss of health insurance would mean less healthcare, and less healthcare would mean more deaths.  But we could just say Trump will be letting people die, if he fulfills his pledge to end Obamacare.  Should we go further and say he’ll be killing people?

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Why Conservatives Should Support Obamacare’s Individual Mandate

For the moment, Republicans are setting aside their seven-year effort to repeal and replace the Affordable Care Act.  A slew of bills failed in the Senate, and now President Trump and the Republican majority in Congress plan on turning to tax reform.  But doubtless, before long we’ll be hearing about the Affordable Care Act again. Not only do conservatives despise it, but even Democrats think it needs work. What I’d most like conservatives to rethink, during this interim peace, is their opposition to the individual mandate.

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The Wrong Reasons? Refusing Elective Abortion Coverage

This week, Community Health Options, Maine’s largest provider of health coverage on the Affordable Care Act’s online marketplace announced that they no longer will offer coverage for elective abortions. The CEO, Kevin Lewis, cited economic considerations, as the co-op has suffered losses that it hopes to make up by cutting some coverage. Continue reading “The Wrong Reasons? Refusing Elective Abortion Coverage”

An APP(le) a Day: Can Smartphones Provide Smart Medical Advice?

I am not going to shock anyone by stating that we live in a time where distrust of government is high, where people believe that they need to ‘take back’ whatever they feel needs taking back. This opinion runs especially strong in matters surrounding healthcare, where people question a range of issues, including: universal insurance, low cost pharmaceuticals, the efficacy of particular medical tests, and autonomy as regards end of life (and other medical) decisions.

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Pricing the EpiPen

American drug prices have long been the object of controversy, from the price hiking on AIDS treatments conducted by the now-infamous Martin Shkreli or the $1,000 per pill Hepatitis C treatment that prompted Senate investigation. The average American spent $695 a year on drugs ten years ago, and now spends $935. Recently, the pharmaceutical Mylan received extensive backlash for the increase in the price of EpiPens, which are used in emergency situations to save someone from a life-threatening allergic reaction. EpiPens now cost $600, a 450% increase from their price in 2004. Analysts have determined that the cost of the drug within each Epipen is about one dollar.

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Consent to Dying: The Case of Julianne Snow

Recently, a 5-year-old child named Julianne Snow passed away from from a neurological disease known as Charcot-Marie-Tooth, causing nerves in the brain to degenerate and loss in the muscles related to chewing, swallowing, and eventually breathing. Although Charcot-Marie-Tooth disease is one of the world’s most commonly inherited neurological disorders, this story made national headlines due to Julianne’s independent decision to refuse treatment.

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Ethics of “Over-the-Counter” Birth Control

Birth control access has been a long debated issue in the United States. Obtaining birth control methods usually means women must go to a doctor’s office in order to obtain a prescription, which can be difficult, for financial reasons or if the hospital is religiously affiliated, for example. On January 1, Oregon’s “over-the-counter” birth control law went into effect, and .

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A Pro-Choice Argument for Investigating Planned Parenthood

Long marked by intense and polarizing opinions, the abortion debate has found its latest controversy. The topic in focus? Fetal tissue donation, in which researchers pay abortion providers for tissue samples from aborted fetuses. Two videos, both published by the Center for Medical Progress, an organization backed by pro-life group Live Action, have brought the issue to the forefront of public debate. In the first widely-circulated video, a Planned Parenthood employee discusses prices for fetal tissue samples, in addition to describing the abortion procedure in explicit detail. A second video, also depicting a conversation about buying fetal tissues for research, shows one Planned Parenthood employee joking that she wanted “a Lamborghini” as compensation.

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