Hey As you can probably tell, I'm
not feeling so good, so I'm going
to be doing most of today's episode from
right here. I've got my Lemsip, I've got
my chimpanzee - let's talk about healthcare.
PART 1 - Personal Responsibility
In the my country the UK we have free healthcare - at time of recording, unless you're one of the several million
people for whom it isn't actually free - and every now and again there's a story in the news about some medical
group restricting the care they provide to
patients who are very fat or who smoke. There was
a famous one a few years ago: the Vale of
York Clinical Commissioning Group said that
patients who have BMIs over 30 or who smoke will have to either lose weight or quit smoking
before they can undergo elective surgery, and Clare Fogues writing the Times recently
said that we need to start thinking about "deserving and undeserving patients."
One of the principles behind ideas like this
is that people who are in some way
"responsible for their own bad condition"
should be denied the healthcare they need,
or deprioritised for the healthcare they need, as
"the best way of achieving maximum value from limited resources."
The result being that they would have to live longer with suffering that could otherwise be alleviated more quickly.
When it comes to who should get healthcare, the classic examples philosophers like to talk about are things like
"Should smokers get lung transplants?"
or "Should alcoholics get liver transplants?"
And whenever these discussions arise, there's an idea often floated called "the principle
of voluntary responsibility." Even if you
haven't heard the name, you've probably
come across something like it before. It goes like this:
Let's say you decide to smoke. Why not? It's addictive and it feels great! But after 40
years of cigarettes you have cancer and you
need a double lung transplant or you are going
to die. But so does Jemima - Jemima has
cystic fibrosis, it's a condition that affects the
lungs. It's genetic - she was born with it - she did not make any voluntary decision
that got her here, unlike your voluntary decision to smoke. And wouldn't you know it, there are
only enough lungs for one of you.
If you hadn't decided to smoke all those years ago she would have just gotten the transplant but because
you now needs those lungs too her future is in jeopardy.
We're going to have to enter some decision-making
process, so there's a chance Jemima might not get those lungs. You've put her at risk by creating
demand for limited medical resources. The
philosopher Jeff McMahan thinks that you have a
moral duty to make sure Jemima gets those
lungs before you do. That's the Principle
of Voluntary Responsibility - if you make a voluntary decision that puts somebody else in
harm's way, you are on the hook for getting
them out of it. McMahan thinks that it is right
for smokers to be denied lung transplants
if there are other people waiting. And that
we could extend that principle to other people as well.
To a lot of people that sounds reasonable
at first, especially in the UK and the USA
where "personal responsibility" is a big
tenet of political and economic philosophy.
"Yeah, if you get sick and it's your fault
why should someone else suffer so you can get better?"
But here's the kicker. 'Smoking' can be substituted for any medical condition that
somebody develops as a result of making any voluntary choice. And 'lungs' can be substituted
for any medical resource, including money and time. If there are enough lungs for both you and Jemima but only
one surgeon, or only enough time in the day to do one operation then Jemima
gets them, every time. And Jemima with her
cystic fibrosis can be substituted for anybody
with any medical condition that they develop through no choice of their own. If you need a lung transplant
because of your smoking but somebody else gets shot in the kidneys and requires a completely different king of procedure, well still, you cannot
get any treatment until they are completely
fixed. That's a logical requirement: the
principle of voluntary responsibility has no room for half measures and arbitrary decisions.
This principle is so much more demanding than a lot of people realise. The philosopher Dan Wikler
points out that if we really committed to
this we would deprioritise healthcare for
every single case of sexually transmitted infection, every single case of AIDS, and every single pregnancy,
except in cases of rape or infected blood transfusion. Because those are all cases in which somebody
needs healthcare as a result of voluntarily
choosing to have sex. So all the cystic fibrosis
patients have to be seen first.
Every attempted suicide who comes in would
get left in the corridor. Maybe even stuff
like food poisoning: you chose to eat shellfish
rather than a veggie burger, you knew the
risks! And again, when I say these would be deprioritised I mean funding for them would be entirely
removed until every single nonvoluntary healthcare
condition was completely fixed. If you're
pregnant you cannot receive a single second
or penny of medical attention until cancer
is cured. If you believe in the principle
of voluntary responsibility that is what you
are logically committed to.
So things get pretty unrecognisable pretty fast if we start allocating healthcare based on who we think is responsible
for their own condition. You might also wondering, just on a practical level, how can
we even tell to what degree somebody is responsible for the state of their health, and it's
funny you should ask that because:
PART 2 - Just on a Practical level, How
Can We

Nnobody ever seems to talk about applying the principle of voluntary responsibility consistently or completely.
In the UK at least it always seems to come down to smokers and fat people
So why? Well, part of the story is that it's to do with risk, especially
if we're talking about surgery. All surgery
carries an element of risk: it's the last
legal bloodsport in England, as a surgeon
once told me. And if you are very fat
or you smoke, that can correlate with other conditions that could mean surgery carries greater risks
for you than it would for somebody who didn't have those other factors. The medical term for other
factors like that is 'comorbidities.' But that prompts the rather interesting question
of how we do measure risk when it comes to allocating healthcare resources?
A study in the journal Bioethics asked subjects
to look at fictional patient files and decide
who should get organ transplants in cases when there weren't enough organs to go around. The
authors asked 283 people, which they admit
is not a representative sample size of the
public, to decide who should get a heart transplant between patients with or without
histories of smoking, with or without histories
intravenous drug use, and with or without
histories of eating high fat diets against
doctors' advice.
"Subjects were significantly less willing
to distribute organs to intravenous drug users
than to cigarette smokers or people eating
high fat diets, even when intravenous drug
users had better transplant outcomes than
other patients. Subjects' allocation decisions
were influenced by transplant prognosis, but
not by whether the behaviour in question was
causally responsible for the patients' organ
failure... People's unwillingness to give
scarce transplantable organs to patients with
controversial behaviours cannot be explained
totally on the basis of those behaviours either
causing their primary organ failure or making
them have worse transplant prognoses. Instead,
many people believe that such patients are
simply less worthy of scarce transplantable
organs... It is not uncommon for people to
argue in favour of allocating resources on
the basis on personal responsibility. What
our study shows is that these arguments may
be convenient ways to support what otherwise
merely reflect social desirability judgments."
In other words, when human beings make decisions about who should get healthcare
we might be vulnerable to making those decisions based not on how much good
could be achieved or on the risk, but who we think is deserving. I say might be vulnerable
because, in fairness, that is only one study
and it has its limitations, like the sample
size. It only investigated behaviours like drug use and smoking as well: it didn't investigate how things
like gender or race might impact healthcare decisions. In her book Fatal Invention,
bioethicist Dorothy Roberts laments that black
and Latinx patients in some studies have been
shown to be under prescribed pain relief compared
to white patients with similar conditions,
and to wait longer for emergency treatment.
Although that study I quoted did investigate how subjects viewed people who have high-fat diets,
it didn't investigate how they view fat people specifically. Fat people are discriminated
against in employment, in education, and even
in court. Being fat is stereotypically
associated with being lazy, and slow, or unintelligent,
it's assumed to be your fault, as if a)
being fat is a problem, and b) social
factors like access to what sorts
of diets are available for who just aren't a thing. Sources for all of that in the doobleydoo
and thank you to Kivan Bay on Twitter
for introducing me to the word of fat studies.
In her book Heavy, communications professor
Helen Shugart examines the various ways Anglophone
countries talk about fatness and obesity,
the contradictions and implications of the
various discourses surrounding it, including
the ones that lean heavily on "personal
responsibility," as well as the downright
myths and junk science. What she highlights
is that, "These questions defy simple answers,
not only or even primarily due to complex
and still unfolding science but because fat
and, accordingly, obesity can only be understood
- indeed, can only mean anything at all
- within the historical and cultural context
in which they occur... Intervention in cultural
or health issues cannot ever be simply about
"the facts," whether because those facts
are themselves a cultural product or because the facts are bad."
But the flipside of the personal responsibility
argument might be that even if we can't tell exactly how responsible somebody is for what
or even whether that idea actually makes sense, I know a freeloader when I see one and I don't want my tax money
going to support somebody who's just going to waste it on self-destructive behaviour.
And if that's your stance then I understand, but I don't really know how to argue with you on that one because
I do want that. I'm okay with my tax money,
what little of it there is admittedly, going to support
somebody who is sick, regardless of whether they are responsible for
their condition, assuming that idea even makes
enough sense to be practically useful, because
I just think that healing the sick and helping people is a good thing to do.
Even if you aren't religious, and I'm not religious either, there is a reason that people used to think healing
the sick was a sign of divine deliverance.
It sucks being ill, it consumes everything
else in your life - you could be the richest person in the world but if you don't have your health you're gonna be miserable. It sucks having to go to hospital, and if I can help anyone lessen
the amount of time that anybody spends in that situation then I guess I just think I ought to do that.
Part 3 - Context & Power
I'm gonna use a little bit of postmodernism
here, so all you Jordan Peterson fans put
your earplugs in now. The French philosopher
Michel Foucault said that in the old days
political power used to control the bodies of individual people. It would publicly execute you or brand
you or torture you if you disobeyed the rules.
Nowadays though, it controls the bodies of
groups of people through what he called 'biopolitics,' which includes things like public standards of
hygiene, public vaccination programs, and,
of course, funding for healthcare. Rather
than dealing with the individual, "Biopolitics
deals with the population as political problem."
And there's an interesting tension there
between the biopolitical standards to which
whole populations are held, and the often very individualistic personal responsibility angle with which we on the ground are expected to engage with healthcare providers.
At its best this expansion of power into biopolitics
produces things like public vaccination programmes,
which help save lives. At worst it produces things
like people with Deafness being banned from
learning Sign and women being barred from getting
abortions. Foucault's point is that power
is never neutral in the norms that it appeals to. No biopolitical decision about who gets healthcare
can ever be unbiased, can ever be immune
to fatphobia, transphobia, ableism,
classism, racism, and whatever, because, as Shugart notes, any appeal to the medical facts presumes
a certain context in which those facts matter.
Thank you for re-joining us Jordan Peterson
fans. That was only a small dose of postmodernism,
so you should be okay. Just as a precaution though you probably shouldn't actually
read any philosophy for at least 24 hours after this. So you'll probably be fine, right?
You might be worried about the ways in which power dynamics can creep into discussions about healthcare.
Like Ted Cruz. He's worried that a system
like the one we have in the UK gives the state
power over human lives. Trouble is though,
that's kindof what states do, unavoidably,
and Mister Cruz can give us a great example of this. Ted not only believes in the death penalty just
as part of his political life, but as solicitor general for the state of Texas defended
the state's right to execute its citizens on five occasions. Now, whatever you think
of the death penalty, you've surely gotta admit that it is definitely
the state having power over human lives. And
even in a country like mine where we try not
to execute our citizens, the government still has power over human lives because
that's what a government does. So rather than deny that power isn't there, I think
it's more fruitful to talk about what flavour of power it is.
There are all kinds of background factors that shape power and how it operates, but because I'm a raging
Leftist SJW I'm particularly interested in
the political economic factors.
The political economic context in my country,
and in the United States, is neoliberalism,
an economic philosophy that not only loves
free markets and individualism, but also uses
the state to create them. For neoliberals,
freedom for humans means freedom of the markets,
and the ideal subject is an individual, isolated consumer. I've discussed neoliberalism in more detail before.
You can see that video by clicking the card that's just appeared in the top-right.
The construction of choice, where 'choice' means a free market, is key to neoliberalism, and it's how it spreads from being a political
economic philosophy to a force that shapes
our lives and even our selves; you might have
seen some American political commentators talking about how they worry a free healthcare
service would deprive them of the ability to choose their providers. Shugart writes, "Neoliberalism
ascribes virtually all responsibility for
personal and social welfare to the individual,
which is further articulated as crucial to
individual liberty under the auspices of choice...
Importantly, this choice is tightly linked
with consumption to the extent that individuals
are expected to choose with their dollars
and thus customise priorities (and goods and
services to the end of realising them) that
matter to them - in this way, exercising
their individual choice is articulated as
tantamount to democracy... Under this framework,
the practical role of government is to facilitate
the market; moreover, government intervention
at any level - in the form of social services,
for instance, or with respect to regulation
of industry - is represented as cultivating
or enabling dependence and, more to the point,
undemocratic, thus hampering if not denying
individual liberties and aspirations."
Of course, it's also true that these markets are great at making rich people
richer. And we might wonder what that choice
really amounts to, especially if you can't
afford healthcare at all. These concerns - profit, politics, "choice" - are important forces
that shape the context of healthcare discussions.
And that's why there's never really
any serious discussion about applying the philosophical principle of voluntary responsibility to its
full extent. Because it isn't really about resource management or personal responsibility; it's about power managing bodies.
As an example, in my country healthcare discussions are
often deliberately held in the framework of "what the NHS can afford" but the NHS could afford to
look after everybody. That is a thing that we could do. Just like we could house every homeless person:
there are more empty houses than there are homeless people; it's not a question
of there not being enough resources. We don't do it because we choose not to, and the same
is true of healthcare. "Limited resources"
are often limited artificially by the choice
to lower taxes, to permit corporate tax avoidance, or to just spend that money on other stuff.
And whether you think that choice is ultimately for the best or not depends on
your political conscience. But in a very wealthy country like mine or the United States, who gets healthcare and where resources
are distributed is a question of choice, not
of scarcity. And so we cannot avoid discussing
the values that will guide that choice.
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