October 31, 2016
by Craig Klugman, Ph.D.
Every four years the United States chooses a new chief executive. Although encoded in the Constitution, the idea that a person with such power would willingly surrender it and walk away to allow another to lead is remarkable.…
October 25, 2016
by Craig Klugman, Ph.D.
A hospital in Paris has opened that country’s first “shooting gallery,” a medically supervised facility where drug addicts can use their injection drugs in a safe, clean environment.…
October 24, 2016
by Cass R. Sunstein, JD
Default rules, taken as such, do not intrude on autonomy, even if they influence people without persuading them.…
October 21, 2016
STUDENT VOICES By Tim Colvin For many faithful Catholics and Christians of all denominations, even for many Americans who are not religious, this election has painted a very stark picture: we are forced to choose between the two most flawed … Continue reading →
October 14, 2016
Health Care and Bioethics DNA database highlights need for new medical privacy protections Creation of a national repository of genetic information is seen by some as crucial to reducing medical costs and improving people’s healthcare. ‘Big data’ could mean big … Continue reading →
October 10, 2016
by Craig Klugman, Ph.D.
Over the last few days, a number of recordings have come to light showing Republican Presidential Nominee Donald Trump saying lewd, lascivious, and down right crass statements about women.…
September 27, 2016
Bioethics as a field emerged in post WWII America during an era of American political stability and international economic and military dominance. Those of us working in the field of bioethics for past few decades, as beneficiaries of this setting, take for granted the American democratic political system and its traditions as the natural context and moral framework for scientific discovery and ethical decision-making. Though we might invoke normative ethical approaches at times on particular issues, from both various philosophical and religious traditions, generally speaking most major ethical dilemmas both at the broader policy level and in particular settings of individual patient care and research issues, must proceed according to well-established procedural rules and standards. The goal of ethical resolution in our democratic context is not to arrive at the ultimate, final, or “the” canonical ethical answer, but to reach a consensus between opposing moral perspectives that preserves a plurality of moral values based on well-established moral and legal democratic principles and values. Thus, bioethics as a field that deals with living, practical ethical conflicts depends on a stable, democratic political system in which people with diverse values and beliefs can find non-violent, indeed peaceful means of finding resolutions to their moral differences. It is in this light that bioethicists should find very concerning what is happening in our presidential election cycle.
Bombast and lack of substance have always been part of American political rhetoric. Normally I would see the role of bioethicists to advocate for policy positions within the political process, but try to remain relatively neutral in attacking or supporting particular political candidates and speaking out so candidly about issues. But in my judgment, this election cycle is an exception. Now is the time for all thoughtful people who value democracy and, in particular, bioethicists should speak out strongly. We are not in a position to take our political order and indeed the framework for moral decision making for granted.
For the first time in post-WWII America, we see ideas under consideration, like deporting 12 million undocumented aliens, which is not only unconstitutional, but, even if it were logistically possible, would cause untold physical and emotional suffering, not to mention in all likelihood an economic crisis; barring Muslims from entering our country, or requiring an ideological test for all immigrants; building a wall between our country and Mexico (in spite of the fact that there are as many people leaving the U.S. as entering); in general we see fabrication of information, character assassination, innuendos, shifting views and talking points, nothing resembling a test of ideas and reasonable exchange of competing views. Some may see such rhetoric and tactics as just more bombast and nothing that could fundamentally change the character of our country. On the contrary, this is one of those potentially disruptive times, much like the McCarthy era, in the life of a nation that could render our basic social and political institutions unrecognizable.
There are growing numbers of citizens in the US with legitimate gripes, who feel their interests have been ignored. As the economy has grown in many specialized areas, as companies have become more efficient in terms of using automation and technology requiring fewer workers, the jobs that built the great middle class in post-WWII America for decades have been eviscerated. Too many of the policies of the past thirty years designed to address these issues, such as lowing taxes on the rich, which many of which these same suffering workers supported, have left them without the skills to participate in a fundamentally different kind of economy and standing little chance to achieve a similar level of wealth as their parents did with the same skills.
This partly explains why a segment of voters are responding positively to extreme proposals even as many admit they cannot actually be accomplished. Because of their fading hope and trust in the system, some of these voters have become iconoclasts—literally someone who seeks to blow up the system regardless of the consequences. Tragically, their despair, as expressed currently in political terms, approaches nihilism. For them the message is clear, the American way of life no longer provides them meaning and purpose.
However, flagging economic conditions alone cannot account for all of what is happening politically. Another part of the explanation also involves evolving cultural and religious norms over the past few decades governing same sex marriage, women’s roles and their reproductive rights, along with greater ethnic and religious inclusion and tolerance—changes that we liberals celebrate as progress and essential to a growing democracy—that are anathema to many on the political and cultural right.
These complex macro economic and sociocultural trends are warning signs and indicative of a vulnerable moment in our history, where a wrong outcome at the presidential level could change the character of our nation for generations, if not forever.
I conclude that this political season is not a normal cycle in the American democratic experiment. It is not a time for thoughtful people and thought-leaders like bioethicists, to remain silent. We must speak out individually and make ourselves heard. Then we must make an effort to better understand the current political conditions and incorporate that understanding into our professional discourse and thinking. Otherwise, we will be ignoring a most fundamental concern, i.e. the very democratic character of our ethical framework grounded in the American political system. We cannot now, or ever, simply take for granted that it will remain intact for future generations.
The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.
August 9, 2016
For a great nation like the United States, it is not only
embarrassing, but also morally reprehensible that there are still millions of
American citizens who in principle could have healthcare coverage but are being
denied that benefit for purely political reasons. Ideologically driven
governors in Red states would rather defy the efforts of President Obama to
expand healthcare coverage for all their citizens than provide this most basic
human service to their citizens. I draw this conclusion simply because their
alleged reason for refusing to expand Medicaid—that expanded coverage will be
unaffordable—is simply not true. With Medicaid expansion, the federal
government will significantly underwrite most of the costs and without states
are on their own in the most inefficient healthcare system possible—they get no
access to basic primary care but if they get acutely sick they can show up at
an ER and utilize the system at time where cost is exorbitant and goals are
limited. It is an abomination how healthcare has been a political football for
decades while people with medical needs are allowed to suffer and die.
But it is not just patients without healthcare coverage who
lack access to medical care—it is also millions of patients with coverage. Medicaid
currently covers over 70 million Americans, yet many of these patients are not
able to find a physician who will accept them. In a 2011 national
survey of physicians, 31% were unwilling to accept Medicaid patients; in
certain states the rates are much higher—for example, in New Jersey only 40% of
physicians accepted Medicaid patients. When reimbursement
rates are increased, these rates of physicians willing to accept Medicaid
patients also rise. Clearly if we are going to expand healthcare coverage in
the United States, we must ensure that physicians are provided a fair
reimbursement for the services. But there are other barriers other than
Another important barrier is the fact that many poor
patients live in areas of the country where there are shortages of physicians.
Up to 60% of the underserved
areas in need of primary care physicians are in non-metropolitan areas. Physicians’
reticence to work in areas with high concentrations of patients whose primary
insurance coverage can be partly explained by lower than average compensation
rates but not entirely. Other barriers may include most physicians wanting to
live in metropolitan areas and not wanting to deal with more patients with
complex issues, such poverty and poor education. Moreover, physician specialist
simply make much higher incomes in larger metropolitan areas. In the past the
choices of individual physicians coincided with the general health needs of
society. It appears that in today’s society, there are serious health needs of
large segments of society going unmet.
But even in Blue states like California, with Medicaid
expansion, many patients have what looks like good health care coverage and yet
are often unable to find a physician or qualified health care professional to
meet their needs. This is particularly problematic for patients with mental health
issues. A recent
story on NPR about a mom with a 12 year-old son provides a great
illustration. To start with this mom is forced to pay high copays of $75 per
session for needed therapy for her son—for working people, living on pay check
to pay check, serious health needs can easily go unaddressed. The 2008 Mental Health Parity Act and the
Affordable Care Act (ACA) insurance companies attempted to fix some of the
problems like preventing insurance companies from charging higher copays for
mental health services than other services. But insurance companies still find
ways to skirt the law “sometimes through subtle, technically legally, ways of
limiting treatment.” The mom
in this story discovered one of those ways when she tried to schedule an
appointed with one of the therapists her insurance company would cover for a
lower copays of $20. The problem was there were no therapists willing to accept
her son. The insurance companies are at least superficially in compliance with the
law, but there are no therapists, or very few, that are available for new
patients. Part of the problem is that millions of new patients with mental
health issues have signed up under the ACA, have coverage, but cannot find a
qualified healthcare professional to care for them.
problems to which I have alluded are characteristic of a healthcare system
filled with inefficiencies and bloated costs. There are many reasons to account
for why these inefficiencies exist, which I won’t get into here. But as a
I am reminded of the Physician’s
Charter from the American Board of Internal Medicine (ABIM), which embraces
a bold, robust set of professional obligations charging physicians to expand
access to medical care for all patients and to promote social justice. Under
the heading of Social Justice, it states: “The
medical profession must promote justice in the health care system, including
the fair distribution of health care resources.”
At my medical school we
are teaching our new physicians they have an obligation to advocate for all
patients and help expand access to healthcare. I must admit I am worried that
the challenges they will face will be nearly insurmountable without significant
change at the political level and many other policy changes, like greater
parity in incomes between specialists and primary care physicians and tuition
debt relief. But, patients, which includes all voters, must do our part too as
citizens involved in the political process and support candidates that in turn
support access to quality public healthcare for everyone. These concerns should
weigh heavily in the choices we make at the voting booth this fall. Getting
basic healthcare coverage for all citizens should not be this hard.