The philosophy of healthcare is the study of the ethics, processes, and people which constitute the maintenance of health for human beings. (Although veterinary concerns are worthy to note, the body of thought regarding their methodologies and practices is not addressed in this article.) For the most part, however, the philosophy of healthcare is best approached as an indelible component of human social structures. That is, the societal institution of healthcare can be seen as a necessary phenomenon of human civilization whereby an individual continually seeks to improve, mend, and alter the overall nature and quality of their life. This perennial concern is especially prominent in modern political liberalism, wherein health has been understood as the foundational good necessary for public life.
The philosophy of healthcare is primarily concerned with the following elemental questions:
- Who requires and/or deserves healthcare? Is healthcare a fundamental right of all people?
- What should be the basis for calculating the cost of treatments, hospital stays, drugs, etc.?
- How can healthcare best be administered to the greatest number of people?
- What are the necessary parameters for clinical trials and quality assurance?
- Who, if anybody, can decide when a patient is in need of "comfort measures" (allowing a natural death by providing medications to treat symptoms related to the patient's illness)?
Ultimately, the purpose, objective and meaning of healthcare philosophy is to consolidate the abundance of information regarding the ever-changing fields of biotechnology, medicine, and nursing. And seeing that healthcare typically ranks as one of the largest spending areas of governmental budgets, it becomes important to gain a greater understanding of healthcare as not only a social institution, but also as a political one. In addition, healthcare philosophy attempts to highlight the primary movers of healthcare systems; be it nurses, doctors, allied health professionals, hospital administrators, health insurance companies (HMOs and PPOs), the government (Medicare and Medicaid), and lastly, the patients themselves.
President Johnson signing the U.S. Medicare bill. Harry Truman and his wife, Bess, are on the far right. (1965)
Ethics of healthcare
Hippocrates, the ancient Greek physician, considered the father of Western medicine.
The ethical and/or moral premises of healthcare are complex and intricate. To consolidate such a large segment of moral philosophy,
it becomes important to focus on what separates healthcare ethics from
other forms of morality. And on the whole, it can be said that
healthcare itself is a "special" institution within society. With that said, healthcare ought to "be treated differently from other social goods" in a society.
It is an institution of which we are all a part whether we like it or
not. At some point in every person's life, a decision has to be made
regarding one's healthcare. Can they afford it? Do they deserve it? Do
they need it? Where should they go to get it? Do they even want it? And
it is this last question which poses the biggest dilemma facing a
person. After weighing all of the costs and benefits of her healthcare
situation, the person has to decide if the costs of healthcare outweigh
the benefits. More than basic economic issues are at stake in this
conundrum. In fact, a person must decide whether or not their life is
ending or if it is worth salvaging. Of course, in instances where the
patient is unable to decide due to medical complications, like a coma,
then the decision must come from elsewhere. And defining that
"elsewhere" has proven to be a very difficult endeavor in healthcare
philosophy.
Medical ethics
Whereas bioethics
tends to deal with more broadly-based issues like the consecrated
nature of the human body and the roles of science and technology in
healthcare, medical ethics is specifically focused on applying ethical
principles to the field of medicine. Medical ethics has its roots in the
writings of Hippocrates, and the practice of medicine was often used as an example in ethical discussions by Plato and Aristotle.
As a systematic field, however, it is a large and relatively new area
of study in ethics. One of the major premises of medical ethics
surrounds "the development of valuational measures of outcomes of health
care treatments and programs; these outcome measures are designed to
guide health policy and so must be able to be applied to substantial
numbers of people, including across or even between whole societies." Terms like beneficence and non-maleficence
are vital to the overall understanding of medical ethics. Therefore, it
becomes important to acquire a basic grasp of the varying dynamics that
go into a doctor-patient relationship.
Nursing ethics
Like medical ethics, nursing ethics is very narrow in its focus,
especially when compared to the expansive field of bioethics. For the
most part, "nursing ethics can be defined as having a two-pronged
meaning," whereby it is "the examination of all kinds of ethical and
bioethical issues from the perspective of nursing theory and practice." This definition, although quite vague, centers on the practical and theoretical approaches to nursing. The American Nurses Association (ANA) endorses an ethical code that emphasizes "values" and "evaluative judgments" in all areas of the nursing profession. The importance of values is being increasingly recognized in all aspects of healthcare and health research.
And since moral issues are extremely prevalent throughout nursing, it
is important to be able to recognize and critically respond to
situations that warrant and/or necessitate an ethical decision.
Business ethics
Balancing the cost of care with the quality of care is a major issue in
healthcare philosophy. In Canada and some parts of Europe, democratic
governments play a major role in determining how much public money from
taxation should be directed towards the healthcare process. In the
United States and other parts of Europe, private health insurance
corporations as well as government agencies are the agents in this
precarious life-and-death balancing act. According to medical ethicist
Leonard J. Weber, "Good-quality healthcare means cost-effective
healthcare," but "more expensive healthcare does not mean higher-quality
healthcare" and "certain minimum standards of quality must be met for
all patients" regardless of health insurance status. This statement undoubtedly reflects the varying thought processes going into the bigger picture of a healthcare cost-benefit analysis. In order to streamline this tedious process, health maintenance organizations (HMOs) like BlueCross BlueShield employ large numbers of actuaries
(colloquially known as "insurance adjusters") to ascertain the
appropriate balance between cost, quality, and necessity in a patient's
healthcare plan. A general rule in the health insurance industry is as follows:
The least costly treatment should be provided unless there is substantial evidence that a more costly intervention is likely to yield a superior outcome.
This generalized rule for healthcare institutions "is perhaps one of the best expressions of the practical meaning of stewardship
of resources," especially since "the burden of proof is on justifying
the more expensive intervention, not the less expensive one, when
different acceptable treatment options exist." And lastly, frivolous lawsuits have been cited as major precipitants of increasing healthcare costs.
Political philosophy of healthcare
In the political philosophy of healthcare, the debate between universal healthcare and private healthcare
is particularly contentious in the United States. In the 1960s, there
was a plethora of public initiatives by the federal government to
consolidate and modernize the U.S. healthcare system. With Lyndon Johnson's Great Society,
the U.S. established public health insurance for both senior citizens
and the underprivileged. Known as Medicare and Medicaid, these two
healthcare programs granted certain groups of Americans access to
adequate healthcare services. Although these healthcare programs were a
giant step in the direction of socialized medicine, many people think that the U.S. needs to do more for its citizenry with respect to healthcare coverage. Opponents of universal healthcare see it as an erosion of the high quality of care that already exists in the United States.
U.S. Medicare (2008)
Patients' Bill of Rights
In 2001, the U.S. federal government took up an initiative to provide
patients with an explicit list of rights concerning their healthcare.
The political philosophy behind such an initiative essentially blended
ideas of the Consumers' Bill of Rights
with the field of healthcare. It was undertaken in an effort to ensure
the quality of care of all patients by preserving the integrity of the
processes that occur in the healthcare industry. Standardizing the nature of healthcare institutions in this manner proved provocative. In fact, many interest groups, including the American Medical Association (AMA) and Big Pharma came out against the congressional bill. Basically, having hospitals provide emergency medical care to anyone, regardless of health insurance
status, as well as the right of a patient to hold their health plan
accountable for any and all harm done proved to be the two biggest
stumbling blocks for the bill. As a result of this intense opposition, the initiative eventually failed to pass Congress in 2002.
Health insurance
Tommy Douglas' (centre left) number one concern was the creation of Canadian Medicare. In the summer of 1962, Saskatchewan
became the centre of a hard-fought struggle between the provincial
government, the North American medical establishment, and the province's
physicians, who brought things to a halt with a doctors' strike.
Health insurance is the primary mechanism through which individuals cover healthcare costs in industrialized countries. It can be obtained from either the public or private sector of the economy. In Canada, for example, the provincial governments
administer public health insurance coverage to citizens and permanent
residents. According to Health Canada, the political philosophy of
public insurance in Canada is as follows:
The administration and delivery of health care services is the responsibility of each province or territory, guided by the provisions of the Canada Health Act. The provinces and territories fund these services with assistance from the federal government in the form of fiscal transfers.
And the driving force behind such a political philosophy in Canada was democratic socialist politician Tommy Douglas.
Contrasting with the U.S., but similar to Canada, Australia and New Zealand have universal healthcare systems known as Medicare and ACC (Accident Compensation Corporation), respectively.
Australian Medicare originated with Health Insurance Act 1973. It was introduced by Prime Minister (PM) Gough Whitlam's
Labor Government, and was intended to provide affordable treatment by
doctors in public hospitals for all resident citizens. Redesigned by PM Bob Hawke in 1984, the current Medicare system permits citizens the option to purchase private health insurance in a two-tier health system.
Research and scholarship
Considering
the rapid pace at which the fields of medicine and health science are
developing, it becomes important to investigate the most proper and/or
efficient methodologies for conducting research. On the whole, "the
primary concern of the researcher must always be the phenomenon,
from which the research question is derived, and only subsequent to
this can decisions be made as to the most appropriate research methodology, design, and methods to fulfill the purposes of the research."
This statement on research methodology places the researcher at the
forefront of his findings. That is, the researcher becomes the person
who makes or breaks his or her scientific inquiries rather than the
research itself. Even so, "interpretive research and scholarship are
creative processes, and methods and methodology are not always singular,
a priori, fixed and unchanging."
Therefore, viewpoints on scientific inquiries into healthcare matters
"will continue to grow and develop with the creativity and insight of
interpretive researchers, as they consider emerging ways of
investigating the complex social world."
Clinical trials
Clinical trials are a means through which the healthcare industry
tests a new drug, treatment, or medical device. The traditional
methodology behind clinical trials consists of various phases in which
the emerging product undergoes a series of intense tests, most of which
tend to occur on interested and/or compliant patients. The U.S.
government has an established network for tackling the emergence of new
products in the healthcare industry. The Food and Drug Administration (FDA) does not conduct trials on new drugs coming from pharmaceutical companies. Along with the FDA, the National Institutes of Health sets the guidelines for all kinds of clinical trials relating to infectious diseases. For cancer, the National Cancer Institute (NCI) sponsors a series or cooperative groups like CALGB and COG in order to standardize protocols for cancer treatment.
U.S. Food and Drug Administration (2006)
Quality assurance
The primary purpose of quality assurance (QA) in healthcare is to
ensure that the quality of patient care is in accordance with
established guidelines. The government usually plays a significant role
in providing structured guidance for treating a particular disease or
ailment. However, protocols for treatment can also be worked out at
individual healthcare institutions like hospitals and HMOs. In some
cases, quality assurance is seen as a superfluous endeavor, as many
healthcare-based QA organizations, like QARC, are publicly funded at the hands of taxpayers.
However, many people would agree that healthcare quality assurance,
particularly in the areas cancer treatment and disease control are
necessary components to the vitality of any legitimate healthcare
system. With respect to quality assurance in cancer treatment scenarios,
the Quality Assurance Review Center
(QARC) is just one example of a QA facility that seeks "to improve the
standards of care" for patients "by improving the quality of clinical
trials medicine."
Birth and death
Reproductive rights
The ecophilosophy of Garrett Hardin
is one perspective from which to analyze the reproductive rights of
human beings. For the most part, Hardin argues that it is immoral to
have large families, especially since they do a disservice to society by
consuming an excessive amount of resources. In an essay titled The Tragedy of the Commons, Hardin states,
To couple the concept of freedom to breed with the belief that everyone born has an equal right to the commons is to lock the world into a tragic course of action.
By encouraging the freedom to breed, the welfare state
not only provides for children, but also sustains itself in the
process. The net effect of such a policy is the inevitability of a Malthusian catastrophe.
Hardin's ecophilosophy reveals one particular method to mitigate
healthcare costs. With respect to population growth, the fewer people
there are to take care of, the less expensive healthcare will be. And in
applying this logic
to what medical ethicist Leonard J. Weber previously suggested, less
expensive healthcare does not necessarily mean poorer quality
healthcare.
Birth and living
The concept of being "well-born" is not new, and may carry racist undertones. The Nazis practiced eugenics
in order to cleanse the gene pool of what were perceived to be unwanted
or harmful elements. This "race hygiene movement in Germany evolved
from a theory of Social Darwinism, which had become popular throughout Europe" and the United States during the 1930s. A German phrase that embodies the nature of this practice is lebensunwertes Leben or "life unworthy of life."
In connection with healthcare philosophy, the theory of natural rights
becomes a rather pertinent subject. After birth, man is effectively
endowed with a series of natural rights that cannot be banished under
any circumstances. One major proponent of natural rights theory was
seventeenth-century English political philosopher John Locke. With regard to the natural rights of man, Locke states,
If God's purpose for me on Earth is my survival and that of my species, and the means to that survival are my life, health, liberty and property — then clearly I don't want anyone to violate my rights to these things.
Although partially informed by his religious
understanding of the world, Locke's statement can essentially be viewed
as an affirmation of the right to preserve one's life at all costs.
This point is precisely where healthcare as a human right becomes relevant.
The process of preserving and maintaining one's health throughout
life is a matter of grave concern. At some point in every person's
life, his or her health is going to decline regardless of all measures
taken to prevent such a collapse. Coping with this inevitable decline
can prove quite problematic for some people. For Enlightenment philosopher René Descartes, the depressing and gerontological implications of aging pushed him to believe in the prospects of immortality through a wholesome faith in the possibilities of reason.
Death and dying
One of the most basic human rights is the right to live, and thus,
preserve one's life. Yet one must also consider the right to die, and
thus, end one's life. Often, religious values of varying traditions
influence this issue. Terms like "mercy killing" and "assisted suicide"
are frequently used to describe this process. Proponents of euthanasia claim that it is particularly necessary for patients suffering from a terminal illness. However, opponents of a self-chosen death purport that it is not only immoral, but wholly against the pillars of reason.
In a certain philosophical context, death can be seen as the ultimate existential moment in one's life. Death is the deepest cause of a primordial anxiety (Die Anfechtung)
in a person's life. In this emotional state of anxiety, "the Nothing"
is revealed to the person. According to twentieth-century German philosopher Martin Heidegger,
The Nothing is the complete negation of the totality of beings.
And thus, for Heidegger, humans finds themselves in a very precarious and fragile situation (constantly hanging over the abyss) in this world. This concept can be simplified to the point where at bottom, all that a person has in this world is his or her Being. Regardless of how individuals proceed in life, their existence will always be marked by finitude and solitude.
When considering near-death experiences, humans feels this primordial
anxiety overcome them. Therefore, it is important for healthcare
providers to recognize the onset of this entrenched despair in patients who are nearing their respective deaths.
Other philosophical investigations into death examine the
healthcare's profession heavy reliance on science and technology
(SciTech). This reliance is especially evident in Western medicine. Even
so, Heidegger makes ang allusion to this reliance in what he calls the allure or "character of exactness."
In effect, people are inherently attached to "exactness" because it
gives them a sense of purpose or reason in a world that is largely
defined by what appears to be chaos
and irrationality. And as the moment of death is approaching, a moment
marked by utter confusion and fear, people frantically attempt to
pinpoint a final sense of meaning in their lives.
Aside from the role that SciTech plays in death, palliative care
constitutes a specialized area of healthcare philosophy that
specifically relates to patients who are terminally ill. Similar to hospice
care, this area of healthcare philosophy is becoming increasingly
important as more patients prefer to receive healthcare services in
their homes. Even though the terms "palliative" and "hospice"
are typically used interchangeably, they are actually quite different.
As a patient nears the end of his life, it is more comforting to be in a
private home-like setting instead of a hospital. Palliative care has
generally been reserved for those who have a terminal illness.
However, it is now being applied to patients in all kinds of medical
situations, including chronic fatigue and other distressing symptoms.
Role development
The
manner in which nurses, physicians, patients, and administrators
interact is crucial for the overall efficacy of a healthcare system.
From the viewpoint of the patients, healthcare providers can be seen as
being in a privileged position, whereby they have the power to alter the
patients' quality of life. And yet, there are strict divisions among
healthcare providers that can sometimes lead to an overall decline in
the quality of patient care. When nurses and physicians are not on the
same page with respect to a particular patient, a compromising situation
may arise. Effects stemming from a "gender gap" between nurses and
doctors are detrimental to the professional environment of a hospital
workspace.
