Sunday, July 22, 2012

Bioethics: Privilege Theory

What is the study of medical ethics?
"Where does it begin and where does it end?" may be a better question. 
I have certainly learned that there are more questions than there are answers in this field and the more you study it, the more questions pop up.

"Don't do dumb stuff" approach no longer sufficient:


I used to like to sum up my course syllabus to my students this way after going through an eight page diatribe of not texting in class, being punctual, etc., I would tell them it all boils down to "don't do dumb stuff."  I admit that I tend to oversimplify at times.  I liked how fellow Buffalo blogger, Shaun Doyle, Jr. wrote about "What ought to be done."  (See his post for a lively read.)
While this is generally a valid approach to life that keeps me out of trouble (for the most part), it is not a sufficient philosophical theory of bioethics given the burgeoning capabilities of medicine and its technological advances.

I am taking a medical ethics class this summer in the philosophy department at Canisius College to transfer to physician assistant school this fall at Daemen College.  Our class is a small group of individuals from diverse backgrounds and perspectives.  Indeed, part of the education here is listening to classmates evolve through their thoughts and begin to embrace new ideas without realizing their own process.  

One person's "dumb stuff" is quite often someone else's "good idea."  This is how we got God committees, such as the one in Seattle in the 1960s. Then the power of the media comes in because it brings with it the power of public opinion.  Dr. Scribner harnessed this power when he took a dialysis patient to a media convention to plea for more dialysis machines in 1962, but it was the God Committee that ended on the front page of the New York Times.  And the power of the media pulled the public and then Congress into the process bring to bear Medicaid and Medicare funding for dialysis. (Medical Ethics: Accounts of Ground Breaking Cases by Gregory E. Pence p. 221.)

The last forty years or so have been a roller coaster ride in medical ethics as transplant and reproductive technologies have raced headlong ahead of our social and legal readiness to encompass them into our healthcare system creating an explosion in the field of bioethics.
Stem Cell

We have studied several important philosophical theories of ethics in my Medical Ethics class and how they intersect with bioethics.

Kantism, utilitarianism, consequentialism, virtue ethics to name a few.

While I can parse my way through a couple of these, I have come to develop my own theory.

Privilege Theory

I have an ethical theory of my own that I am calling, "privilege theory."
And I don't mean "privilege" in the sense of affluence. A privilege is a vantage point from which one person can lift or assist another onto a higher level or plane.
I believe that each of us has privileges that it is our duty to pass on.  It may be as simple as holding a door for the person behind you entering a building, sharing a smile, or teaching a simple life skill to someone who may benefit from such whether it is your child or a stranger.  All of us have privileges that it is our obligation and gift to pass on.  When we fail to pass on or share a privilege because we are too tired or selfish, we smother it and lose an opportunity to not only lift up another individual but also a chance to liberate some small part of us that needed to be set free.  It's like finding a great free snack sample at Wegman's (a great grocery & deli store in WNY) and not telling another shopper!

Privilege Equalization

How we choose to share these privileges is, of course, up to each individual.  In the interest of theory discourse, we could call this "privilege equalization."
We must equalize our privileges.
This may sound socialist but I don't intend
it as a financial matter of dispersing property and assets.
We all have privileges to share.
We each have something within us that we can use and share to lift up another.  That thing may be an education, a skill or a well timed hand shake at the right moment.

How do we use this theory to decide who gets scarce medical resources?   Which patient will be able to receive that much needed organ transplant?  How do we decide these ever more complicated decisions?

The limited answer is that we keep handing up privilege with each action and each person who can serve the one who needs them at that moment.  That means we all check off the organ donor box on our driver's licenses and let loved ones know that we want every usable piece of tissue, bone and organ harvested before our body is put to rest.  And it means that we continue as a nation to dialogue and struggle to bring forth a national health care system that serves our entire nation.

Healthcare in Europe


I was recently in Europe when a German traveler engaged me in a conversation on a flight to Moscow.  He wanted to know two things:
  1. Who will win the election this fall, Mitt Romney or Barack Obama?
  2. And why don't Americans want to have health care for their country?
"I don't know who will be the next President," I told him.  My uncle, a family physician who was traveling with me, and I tried to explain the complex state of medicine and public opinion in the U.S. to our German friend.  We spoke with citizens in Germany, Hungary and Russia about their healthcare and insurance options.  Europeans seem perplexed by America's lack of a consensus for quality healthcare for all of its citizens.  This seems a simple right or need to them and they are watching us in puzzlement.

In Hungary, it seems that physicians make low salaries relative to their education and work.  Many doctors in Hungary work in multiple capacities to increase their earnings.  And patients and their families go to the hospital with envelopes of cash that they give to doctors and nurses when a patient's outcome was satisfactory or pleasing.  So basically, they are tipping their physicians according to their performance. 


Privilege Theory in Medicine

Those who choose to study medicine are privileged folk.  And note that I am describing all aspects of medical care here, not only physicians, but also nursing, radiology techs, occupational and physical therapists, clinical lab techs and all who work in healthcare.
They are privileged because they have the ability to study hard and apply themselves to a chosen field, often to serve others.  They have an inherent duty to act responsibly in supporting their patients medical needs in their particular aspect of care.

How we distribute these privileges may be a function of one's political or philosophical alignment with utilitarianism or other forms of theory that applies a basis for bestowing justice and merit.  But if each one adopts the ideal of sharing their privileges faithfully and honestly, some needs may fall away.  Imagine for a moment, the patient being seen for sore ankles, knees and foot pain who is overweight and works on their feet.  Is it wise for their caregiver, to advise them how to treat their joint pain and foot discomfort without also sharing direction with them how diet and exercise may help them reduce their weight and therefore their joint and foot pain?  By sharing the privilege of understanding how someone may improve their health and lifestyle, we can alleviate other disease processes and treatments in the future.

We should not have to be "tipped" with envelopes of cash to be motivated to share the privilege of this knowledge with each other.

This is more of a practice run of me thinking through my personal philosophy and how it fits with various ethics theories than it is an espousement of how things really are or actually should be.