Two facts lying at the foundation of healthcare explain its moral challenges
Welcome to part two of the Chasing the Essence of Healthcare series. There is a multitude of moral imperatives and dilemmas in healthcare, which are spread out throughout several parts of the system. If our goal with this series is to shed some light on healthcare, morality will be a great place to start.
Consider for instance the following list. The first example is a moral imperative, and the rest are dilemmas:
Why do we all feel deeply compelled to support the ill?
What should be considered an individual’s responsibility when it comes to his or her health? What should not?
Should anything be provided for “free”? If so, who is a qualified recipient?
If there are limited resources, how should a community choose between building a facility for terminal cancer patients versus building a relief place for children with disabilities?
One of the guiding principles of medicine is First do no harm. What does this principle tell us about the limitations of modern medicine and what is at risk for the patient?
The purpose of this essay is to argue that two fundamental facts precede all these questions (and any other moral-related ones). In other words, the numerous moral imperatives and dilemmas in healthcare actually result from two facts. It’s as if they lie at the foundation of healthcare, and everything else is a consequence of them.
The two facts are: (1) human life is considered sacred, and (2) many diseases are still unsolved problems, i.e. there is no reliable cure.
The enormous value attributed to all human life
The first fundamental fact to be highlighted is that each human life is considered sacred by pretty much everyone (sacredness in the sense that it begets the highest protection).
I am not well versed about the most credible research and explanations for why this is true. Since such high value seems widespread across time and cultures, my guess would be that some kind of deep level of empathy has been evolutionarily hardcoded in us, human beings.
The sacredness associated with human life is unlikely to change any time soon. I would argue that in order for there to be a decrease in the value given to human life, there would need to be an easy way to fully duplicate human beings. Because there is no way to duplicate our genetics and personal experiences, there is a gigantic uniqueness attached to each one of us.
Regardless of why human life is sacred, or how it could change going forward, for our purposes here, it’s sufficient now to acknowledge that we do confer enormous value to each and every human life.
Many diseases are still unsolved problems
The other fundamental fact is that many diseases are still unsolved problems. Problem because diseases bring profound suffering to mankind, and unsolved because, despite technological advances, many diseases are still without a cure.
In order to frame and have an insightful perspective on disease, one must take a step back and start by thinking: what do people die of? The causes of death can be categorized into three buckets: violence, accidents, and nature. Violence is the act of humans intentionally killing other humans (war, crimes, suicides, etc). Accidents are unintentional deaths, usually due to the failure of a man-made machine (car accidents, electric shocks, plane crashes, etc). Nature consists of all other causes of death (animals, microorganisms, diseases, etc).
Many of our social structures exist in some ways to manage the violence that occurs between humans. Similarly, accidents can be prevented by managing our behavior and improving the safety of the systems that we have created. I would like to focus on death by nature, as it is our primary concern in today’s healthcare.
In order to examine death by nature, let’s subdivide it into categories as well: death by exposure to the elements, death by hunger, death by wild animals, and death by disease. You may be asking yourself: where does aging come into play? I believe it’s in the same category as diseases. I subscribe to the hypothesis that aging can be viewed as a kind of slow, progressive, and silent disease (one that spans decades).
The first key insight here is that, as mankind has come to understand more of how nature works and how to manipulate it, we have been progressively solving death by nature. Quite interestingly, in doing that, we have also removed the veil of mystery that used to confuse us about nature itself.
Take the elements for example. Try to imagine how hard it was for ancient civilizations to comprehend and cope with droughts, floods, wildfires, etc. For many centuries, there was nothing they could do but blame the gods (despite it not being an effective solution).
Next, let us look at hunger. We have solved hunger on a very large scale with agriculture, a total game-changer millennia ago. Due to innovations in the last 100-150 yearsThe 20th century yielded remarkable gains in agricultural productivity as well as better hedging against the elements (by spreading crops across geographies).
, food for billions of people is now a reality, and a reality that we not only take for granted but one that is such a reliable default that we mistake it for trivial. The average present-day human being sees no mystery there.
In regards to death by animals, urbanization and firearms have made the menace of wild animals much less relevant (note that microorganisms like bacteria and viruses are not animals).
Looking to all things that kill people, it seems fair to say that the only oneI am not arguing that there are no serious challenges with hunger and the elements, we still need to improve our human systems to better cope with them (and with violence and accidents as well). My point is that there’s no mystery around them anymore.
that still remains a mystery is disease. I’d even extrapolate those observations about our past and argue that in years to comeThe consequences of ending death are very, very profound: it would affect evolution, it could lead to sooner resource exhaustion, it could lead to social stagnation, etc. We may discuss them in the future, but that is out of our scope today.
we will look back and be baffled by our current response to disease, much like we now do when we think (in retrospect) about the elements and hunger.
Why haven’t we been able to cure all diseases? It turns out that it is an extraordinarily hard problem. Disease can be seen as our bodies not functioning well, but the human body is by far the most complex thing we have ever dealt with.
It may sometimes be difficult for us, laymen, to really appreciate how complex it is. For example, there are trillions of cells in a single body, each of them carrying out an intricate and continuous web of molecular interactions. These interactions are neither reasonably understood nor, even worse, observable by us. In other words, our current toolbox is severely limited in its ability to evaluate and intervene in something so utterly complex such as our bodies.
It’s not that we’ve been completely stuck against disease, though. As mentioned in a previous essay of mine, during the 20th century, we made impressive headway in figuring out how to neutralize several of the most relevant invaders (viruses and, especially, bacteria) that plagued mankind for centuries. These invaders caused the Black Death, which in the 1300s devastated 75-200 million people in just 10 years, and diseases like tuberculosis and pneumonia, that killed millions of people worldwide per outbreak. Fortunately, these are much less of a problem nowadays.
The proliferation of moral issues
Now that we are familiar with the two facts, let me argue why I believe they are responsible for the moral issues that exist in healthcare. Simply stated, if these two facts didn’t exist, would the moral issues still remain? These two fundamental facts are necessary conditions for these moral imperatives and dilemmas to happen.
With the above argument in mind, let us inspect the following moral issues in the diagram below:
There is at least one relevant moral consequence directly connected to the first fundamental fact, the high-value attributed to human life:
1. Moral imperative to support the ill
Offering support to the sick and disadvantaged is seen as a universal moral imperative. If it was not for the value we (subconsciously?) give to human life, I believe we would not be so compelled to help those in needThis is a belief of mine, and I can’t really prove it. It is very possible that we deeply empathize with those that are suffering, not because of any particular value given to life, but just because. Empathy and suffering do play a crucial role in healthcare (I will expand on it in my next post), however, I believe that the high-value given to human life precedes them.
Next, here is one moral consequence resulting from the second fundamental fact, that diseases are an unsolved problem:
1. First do no harm
This is, as mentioned before, one of the guiding principles of medicine, but what does it mean? One could interpret this saying as an ask for doctors to be very cautious with the treatments they prescribe, but I interpret it to have a deeper meaning. It is, in my opinion, a testament to how challenging it is to solve disease. Despite our efforts, all sorts of things can still happen from side effects that could go hidden for years to, and in some cases, the body self healing on its own. Again, if diseases were not unsolved problems, I believe we wouldn’t find ourselves so clueless.
What other moral consequences are there because of the two fundamental facts? I believe that there are at least four other moral consequences descending from both facts:
1. Any risk of harm must be vetoed
Terrible abuses with human experimentationSee the Nuremberg Code, a response to the abuses made by the nazis in human experimentation. For a case of abuse in the U.S., see the Tuskegee Study of Untreated Syphilis in the Negro Male.
happened in the 20th Century in the name of “scientific progress”. To make sure such abuses would never happen again (they clearly defy the highly value placed on human life), institutions were created to oversee clinical studies. The pendulum has swung to the other extreme, and today any medical study that presents risk of harm is simply vetoed. Institutions, in effect, now decide on behalf of the patient, denying he or she from taking any risk with his or her own health. Here lies a tricky moral question, what if such risks are taken voluntarily and have the potential of helping others down the line? For instance, should a volunteer, fully aware of all consequences, be allowed to participate in a clinical trial where the effects are unknown and maybe harmful? Or, should the immediate risk of harm prohibit the volunteer from participating, thus jeopardizing a potential future benefit? Can the pendulum be held at any non-extreme pointUnless the potential future benefit is less potential and much more concrete, I don’t think anything will change there.
2. Right vs Privilege vs Responsibility
Since resources are limited (time and money being obvious examples), we are used to making trade-offs in resource allocation everywhere across society. In contrast, given the two fundamental facts, trade-offs in healthcare can be highly charged and very unsettling (esp. for the professionals inevitably making the decisions). Coupled with this, the two fundamental facts also blur the lines between which healthcare services are rights, and which ones are privileges and/or responsibilities. The end result is that, instead of having your typical economic market (based on competition, prices, and profit motive), conducting resource allocation in healthcare is significantly more convoluted.
3. Emotional vulnerability asks for confidentiality
In the presence of disease there is always a heavy emotional load due to the fear of irreversible losses (i.e. death). This emotional reaction can appear in the form of physical pain and anxiety that exists when irreversible loss is a possibility. In conjunction with pain and anxiety, comes the feelings of impotence and vulnerability, which most respond to by treating health information as intimate and confidential. I believe that solving disease would eliminate many parts of this emotional burden, and would lessen the moral imperative connected to confidentiality.
4. Inevitable, Acceptable, or Desirable?
No one has ever escaped death, and quite reasonably, this explains why death is considered to be inevitable. We digest the inevitable by making it into something acceptable. Simply accepting a seemingly inevitable fate, instead of choosing to worry, does sound more reasonable, however it doesn’t end there. Some go further, choosing to twist the acceptable into the desirable. Isn’t that shocking? Still, it is common to come across variants of my life only has any meaning because I will die.
Do you recall that I suggested that in due time we’ll look back and will be baffled by our current civilizational responseI will not spend time discussing the sacredness of human life, the other fundamental fact, as I believe solving the existence of disease will happen before duplicating another human being.
to the unsolved disease problem? That’s the kind of thing I had in mindMy strong stance against the “desirability viewpoint” may seem weird (or even absurd), but I firmly believe that such viewpoints are holding us back and should be called out.
So, what to make of all this?
As much as I would describe myself as an optimist, who believes we will eventually have broadly available cures for all deadly diseases (and thus clear up some of the moral challenges), I believe this could take several decades. Meanwhile, most of our current institutions in healthcare will still be in place and in this case we must understand the important roles they play, as well as their virtues and limitations.
Healthcare systems, in particular, are the way that we, patients, cope with diseases, both trying to weaken the ones that still kill us and administering the cure to the many other ones that are not lethal. We should also note that healthcare is responsible for providing society with the resources necessary to deal with the consequences of accidents and violence (especially provided by trauma specialties).
Let’s set aside the two fundamental facts for now, as we will definitely be referring back to them, and let’s start examining healthcare from the eyes of the ultimate beneficiary, the patient.
- Why bother?
- Precious creatures, unsolved problems, and morality (you are here!)
- What does the patient need?
Chasing the Essence of Healthcare is a series of essays where I try to deconstruct the complexity of healthcare systems into a few distilled fundamentals.
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