Grounds Vol. 2, Iss. 1

GR OU ND S. THE VIRGINIA JOURNAL OF BIOETHICS

From the Editor-in-Chief

LOGAN ALEXANDER BRICH

EDITOR-IN-CHIEF

Whose Story to Tell?

Case Study

"PREGNANT MINORS ARE CONSIDERED ADULTS IN VIRGINIA"

THE PAIN PROBLEM

BY PACO ABIAD

LOOKING BACK, I admit that it got out of hand. By the end of high school, almost every other morning’s breakfast was accompanied by Advil painkillers. It was routine; it was easy. Every morning that I woke up with aching bones and muscles, was a morning that I took painkillers, simple as that.

To be clear, I was not a proli c studentathlete bound for the NCAA. I was just an average pole vaulter trying to survive my year-round training, and recovering from past injuries. At the end of the day, I was a normal person trying to get through my day. That’s the problem: normal people struggle with daily pain, and consequently, many people have access to painkillers. If I ever needed an extra dose of pain relief during the school day, I had a long list of friends that I could call upon to supply me with more painkillers.

My seemingly harmless affinity for Advil highlights some risky behavior patterns: constant pain, habitual reliance on medication, a network of suppliers--all factors related to potential abuse. This story could be very different had I been prescribed a stronger painkiller by my doctor to deal with my pain. Would I have been able to draw the line between proper use and addiction if I were on a stronger medication? What is the distinction between frequent use of over- thecounter painkillers and opioid abuse? Is it possible that the culture of accessible nonprescription painkillers is the gateway to opioid abuse?

“Please rate your pain on a scale of 1-10.”

This is the phrase that medical professionals are accustomed to asking their patients when assessing their various injuries, often accompanied by scales such as the Wong-Baker FACES Pain Rating Scale. The FACES Scale features an arrangement of six different faces, each associated with a different level of pain, ranging from“no hurt” to “hurts worst.”

The problem with this method is that it asks for a self-reported measure of pain, but does not necessarily measure pain tolerance. The point on the scale at which the pain goes from manageable to unbearable depends on the individual; because of this, people seek opioid prescriptions at varying levels of pain.

In this day and age, there are prescriptions for just about everything, biomedical “cures” for anxiety, attention issues, insomnia, and most especially pain. To paint a brief picture of just how out of hand the problem has become, providers wrote nearly a quarter of a billion opioid prescriptions in 2013, and sales of prescription opioids in the U.S. nearly quadrupled from 1999 to 2014 [1].

Despite this increase, Americans have not reported changes in their overall pain levels during this time period. Even worse, opioid addiction rates have increased, as seen by the 900% increase in people seeking treatment for opioid addiction from 1997 to 2011 [2]. These statistics paint quite a grim picture of the undeniable opioid epidemic in this country. Clearly, the rise in opioid prescription rate is not solving the problem of pain in America.

These statistics are not just headlines meant to scare the public. I have seen firsthand what unbearable pain can do to a patient during my time observing a pain doctor. When pain becomes too much to bear, these patients can become irritable and unreasonable. The only solution that they see to relieving their pain is a narcotic prescription, but sometimes that is not the best route to take. People don’t act like themselves when they let pain rule their lives. When the doctor I worked with hesitated or refused to prescribe these powerful yet addictive substances, patients threatened to leave and find another doctor who would give it to them.

“They don’t want my help, only my ‘scripts,’”my doctor would lament to me, gesturing at his unused prescription pad.

When it comes to prescribing pain medications, doctors are faced with a moral dilemma. The primary problem is a matter of obligation: the doctor has a responsibility to make the best medical recommendation while respecting his patient’s autonomy and wishes while finding the balance between alleviating pain and preventing addiction. If a doctor interferes with the patient’s autonomy in a paternalistic manner, on the grounds that the doctor knows best, it is possible that not all obligations will be met. Also, doctors may feel that they do not have enough time to fully present all of the options to the patient in order for the them to make a fully informed decision.

Additionally, if patients are not satisfied, they might turn to “doctor shopping”— if their primary doctor does not provide the treatment that they want, in this case narcotics, they will search for one who does.

The opioid epidemic is not the stereo typical“dark alley and drug dealer”story that wemightenvisionat rst.Therealstorybegins with everyday people going to their doctor’s o ce seeking relief from their pain and su ering. Doctors are becoming more aware of the long-term effects of opioid use, such as increased chance of addiction. But when they attempt to limit the number of opioids prescribed, addicted patients might turn to the black market, where pills are plentiful.

If and when the black market cannot supply their needs, “people who would never have dreamed of shooting up, like suburban moms and middle-class professionals, will seek respite from the pain of withdrawal with the more

"IS IT POSSIBLE THAT THE CULTURE OF ACCESSIBLE NONPRESCRIPTION PAINKILLERS IS THE GATEWAY TO OPIOID ABUSE?"

Background: "Ethanol." Watercolor. By Mary Spitler.

potent method of dissolving and injecting the pills’contents, or going straight to heroin” [1]. Prescribing opioids can lead to a domino effect and open the gateway to illicit substances, as patients search for any means necessary to alleviate their suffering. These are ordinary, wellmeaning people who are in extreme pain making irrational decisions. The opioid epidemic is a problem that must be addressed by the government, health care systems, and every day people alike. The biggest responsibility, however, falls upon patient and practitioner. Doctors must stick to their gut when choosing not to prescribe narcotics, since they are the most educated on the risks of long term use.

[1] Calabresi, Massimo. 2015. “The Price of Relief. (Cover story).”Time 185, no. 22: 2633. Academic Search Complete, EBSCOhost (accessed December 19, 2016).

[2] Kolodny, Alexander. “ The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction.”

January 12, 2015. (accessed December 19, 2016). http://www. annualreviews.org/doi/pdf/10.1146/annu rev- publhealth-031914-122957 [3] National Institute on Alcohol Abuse and Alcoholism. “Alcohol Metabolism: An Update.” Alcohol Alert 72 (April 2007).

Accessed December 27, 2016. https://pubs.niaaa.nih.gov/ publications/aa72/AA72.pdf.

[4] Sanusi, August, Dr. E-mail message to author. November 23, 2016. Accessed December 19, 2016).

REISE | PAGE 4

There are alternatives to narcotic prescriptions, which include but are not limited to: Gabapentin, Cymbalta, Lyrica, Lidoderm patches, Voltaren gel, and even TENs (Transcutaneous Electrical Nerve Stimulation) units. The main challenge that physicians face is to simultaneously relieve pain and prevent addiction [3].

Additionally, instead of a quick consult, physicians must take the time to sit down and educate their patients. There is power in conversation, a phrase that could not hold more true in this situation. Ideally, primary prevention of opioid addiction is to not prescribe the medication in the first place, but the next best option is to arm the patient with knowledge. A healthy relationship between patient and practitioner can be the lynchpin to fighting the problem of pain.

References

MORAL EXPERTISE, CLINICAL ETHICS CONSULTATION, AND THE INCREDULOUS BROW

ABRAM BRUMMETT

It is the mark of a modern moral education to respond to virtually all questions of right and wrong with the dismissive quip,“who can say?” As such, when clinical ethics consultants claim to possess “moral expertise”—defined as knowing what ought to be done—it often raises an incredulous brow from the educated other. I will argue that this brow can only be raised so high —by which I mean, complete moral skepticism is a logically untenable position.

Furthermore, skeptics of clinical ethics often opt for a clinical morality solely focused on respect for patient autonomy. But I argue that this move also articulates an implausible standard for moral decision making in the medical context. Respect for autonomy is a necessary but insufficient principle for resolving moral dilemmas. If one begins to entertain ways to limit autonomy, one has merely entered into the realm of articulating a more robust moral system. Therefore, though the skeptic may begin with “who can say?” they must end by engaging in the difficult work of theoretical clinical ethics. This work requires a conception of moral expertise that takes one beyond moral skepticism or pure autonomy.

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As the standardization of clinical ethicists looms, theorists are forced to either abandon or articulate a notion of moral expertise, defined as “knowing what ought to be done.” I adopt this definition from recent work by bioethicists Ana Iltis and Mark Sheehan, who write, “To be an ethics expert [...] is to be an expert in knowing what ought to be done” [11]. It is precisely this notion of moral expertise that has invoked the most vitriolic criticism of clinical ethics consultation (CEC). The idea of a credentialed ethicist seems to conjure fears of one person saying to another, “Don’t get that abortion! It’s ok, I’m an ethicist, here’s my badge.” As a skeptic of moral expertise, Giles Scofield writes, “[T]he ultimate problem with the claims ethics consultants make is that they cannot be true in a pluralistic, democratic society founded on the belief that each person is the moral equal of every other” [15]. Another outspoken critic of moral expertise, Christopher Cowley, emphasizes the distinctly personal nature of ethical perception, which means “all these fancy ethical theories and principles,” which are supposed to tell us what is right and wrong despite our personal preferences, “lack

normative force” [2]. Cowley goes on to add, “The mistake is to believe that moral philosophers have some added authority to which non-philosophers should defer just as I defer to my dentist: such a belief would make the philosopher’s behavior no t‘professional’, but presumptuous, moralistic, and preachy” [2]. The words of these critics exemplify the often emotional rejection of the idea that anyone could be better at knowing what ought to be done than anyone else.

To justify this skepticism of CEC, critics point to disagreement between so-called moral experts (1). Some evidence suggests that ethicists lack continuity among their recommendations in all but the easiest cases. These findings, which studied recommendations for patients in persistent vegetative states,have not changed significantly from 1991 to 2003, despite e orts to publish guidelines for appropriate treatment [6, 13] (2). Few are willing to contend that mere disagreement threatens the legitimacy of a discipline, as such a view would immediately undermine all disciplines. However, it is the radically fundamental nature of the disagreements among ethicists that critics often point to. A critic of clinical ethics experts, Renford Bambrough has claimed that they “disagree so much and so radically that we hesitate to say that they are experts” [1]. If knowledge were shaped like a tree, noting the location of the prevalent disagreements between experts drives the point home — where established disciplines may see expert disagreement in the leaves, ethicists disagree in the roots.

Others argue against ethics expertise by pointing out how ethics fails to measure up to gold standards of expertise—typically taken as medicine and science generally.

Ruth Shalit concisely states, “The problem with all this is basic. ‘Clinical ethics’ is not medicine, which is to say it is not science, which is to say it is to a very large degree whatever anyone wants it to be” [16].

Bernward Gesang argues that expertise is stronger in science because there is an emphasis of experience over theory —meaning our experiences do more to shape what theories we hold. In ethics, there is a 35

stronger emphasis of theory over experience— meaning our theories do more to shape how we see the world. He writes, “Moral experience is influenced by the concrete subject, its preferences, traditions, and so on. That is different from empirical science” [7]. On this view, because morality does not work like science, it does not admit of expertise.

The primary thrust of these various skeptical arguments has been to establish doubt with regards to moral expertise on grounds that are either ontological (there are no moral facts) or epistemological (there may be moral facts but we cannot know them). Dien Ho succinctly summarizes the epistemic version of the argument this way: 1. We do not know which ethical and metaethical theories are correct.

2. If we do not know which ethical and meta-ethical theories are correct, then ethical expertise is impossible.

3. Therefore, ethical expertise is impossible [9].

This is an ancient but powerful indictment of moral expertise, as philosophers have spent millennia in search of objective moral foundations. In light of their failure, how can a basis of right and wrong be determined?

Tristram Engelhardt provides what is a wellknown and forceful articulation of the skeptical position. He argues that, in the case of ethical theories, the primary difficulty is that they always end up presupposing what they set out to prove —they beg the question. The postmodern era in which we now find ourselves is a testament to the truth of the first premise above. In chapter two of The Foundations of Bioethics, Engelhardt marches through the various attempts to justify a content-full secular ethic to show how they all fail in a similar way. Regarding the failure of consequentialism to provide a content-full secular morality by use of reason alone, he writes:

“[O]ne may attempt to resolve moral controversies by comparing the consequences of different systems of moral choices. But how can one assay the comparative virtues of competing systems without appealing to a background moral understanding that will allow one to assess the relative merits of the competing systems? The possibility of establishing such an understanding is exactly what is at issue. [...] One must already have a vision of the good in order to rank consequences.

One cannot appeal to consequences to determine the correct ranking of consequences [4].”

To see why all attempts to justify a particular moral lifeworld are unsatisfactory, begin with the assumption that all moral beliefs require a justification in terms of a reason why one holds that moral belief (3). Then pick any moral belief and ask yourself what reason you have for holding that belief. You will either produce a reason, or you will not. If you produce a reason, just repeat the question for that reason. Either this process will continue forever, will reveal circularity, or you will end in a belief for which you can give no further reason (4). These “basic” moral beliefs are not established by reason, they are merely presupposed (5). For Engelhardt, they have the character of being arbitrary and conventional [4]. We remain so deeply divided on moral questions because the Enlightenment promise to adjudicate moral truth with reason has failed [4]. We are intractably divided because our most basic moral beliefs are presupposed, not discovered with reason. He writes, “Appeals to reason alone will provide only logical constraints, not moral content and concrete directives” [4]. How is one to proceed in such a situation? Upon what basis can one claim that one action is right and another wrong? Without a basis, how can one claim to be better at resolving moral questions than anyone else? If no one can make this claim, how can there be moral experts?

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Two Responses: Moral Skepticism or Radical Autonomy Although these skeptical arguments hit hard, I will argue that the positions they often lead to with respect to clinical ethics consultation are untenable. Some may be tempted to adopt radical skepticism with respect to moral claims, and, by extension, clinical ethics consultation—arguing that because there is no moral knowledge, clinical ethics consultants have no role to play in “helping” to resolve medical moral dilemmas. However, this position suffers from a self-defeat problem. No critic of normative expertise can consistently doubt that any justified normative claims exist while simultaneously telling clinical ethicists that they ought to not go around telling people what to do. Such a radical position denies the existence of any justified normative claims, then attempts to make a justified normative claim. Gilbert Harman puts the objection as follows with respect to moral relativism in general. He writes that relativism is defined as the assertion that: (a) there are no universal moral principles and (b) one ought to act in accordance with the principles of one’s own group, where this latter principle, (b), is supposed to be a universal moral principle [8].

The skeptic here seems to have exchanged one problem (the justification problem in ethics) for another (the self-defeat problem of relativism).

The Failure of Mere Autonomy Turned off by the problems of radical moral skepticism, critics are left with emphasizing an ethic based on respect for patient

autonomy. Because our society lacks shared meta-ethical foundations, it is left up to the individual to decide the good for themselves. On this view, ethics expertise is a subjective standard, where individuals are allowed to settle metaphysical, epistemological, and moral questions how they see fit. Clinical ethics consultants are not needed to “help” patients make “better” decisions. Rather, we need only ask the patient what they want and proceed as directed.

Lisa Rasmussen has made a barrage of objections towards this merely proceduralist view—so called because it supposedly issues no substantive moral claims. Rasmussen first points to cases where the subject lacks capacity to make decisions, and a decision must be made. In these cases we commonly refer to a surrogate, but determining who that surrogate should be will immediately introduce substantive moral judgments to the process. Additionally, the values of the patient may conflict with the values of others affected by the decision, and a decision must be made regarding whose values will win out in these cases. As Rasmussen points out, “A clinical ethics decision is almost never only about an individual and her wishes” [14]. This view also fails to recognize that the patient often selects a decision from the choices presented by the health care provider. A myriad of outside influences (policy, law, sociopolitical structures) govern the range of possible options put before the patient and determining what those options should be may not be a straightforward process.

Another deeply contested feature of the pure autonomy view is whether respect for autonomy is to be understood as a substantive moral claim, or, as Engelhardt has argued, a basic, contentless requirement for moral action [4]. For the moral skeptic, autonomy cannot serve as a substantive moral claim because they have already argued that no justified substantive moral claims exist. From the skeptical view,

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respect for autonomy is just as arbitrary or conventional as any other moral claim and therefore has no right to serve as a justified foundation for a moral system. On the other hand, if respect for autonomy is to be understood as a basic, contentless constraint on moral action, trouble looms the moment the details get filled in. Do all people deserve respect for their autonomy?

Who counts as a person? Does one have full autonomy at birth or does it develop over time? When should autonomy be considered “fully developed”? What counts as a competent decision? Autonomy is closely related to metaphysical views of property. If I am permitted to rule over myself and all that I own, when do I come to own something. How is ownership lost or transferred? The philosophical questions quickly mount, and with them, difficulties for the view that autonomy can be understood purely as something “contentless” and “basic.”

Rasmussen summarizes the challenge by asking whether any wish expressed by an individual, no matter how extreme, ought to be honored? If yes, then we run aground the absurd notion that ridiculous patient requests are to be honored by medical staff. As Rasmussen says, this would “require moral agents interacting with that person [...] to ignore simple, obvious, remediable problems with decision making” [14]. However, the moment one admits there are situations wherein patient requests are justifiably limited, then one is committed to moral principles that extend beyond mere autonomy, and, as a result, has moved beyond proceduralism.

What Ethicists Actually Do It seems that some of the authors writing against moral expertise are motivated by the fear that permitting ethicists to make a claim to moral expertise will get out of hand. This is the sort of situation Cowley imagines when he writes, "The ethicist

comes to the committee and makes his moral judgment ‘euthanasia should be legalized’ and offers his reasons (utilitarian, deontological) etc..” [3]. But does such anvision really capture what the clinical ethicist does?

The American Society for Bioethics and Humanities (ASBH) report outlining the core competencies for health care ethics consultation describes three main approaches to health care ethics consultation [10]. The authoritarian approach places the ethics consultant as the primary decision maker with views “more correct or important” than the other involved stakeholders. This approach reflects what critics of the field seem to think clinical ethicists do, but it is explicitly rejected by ASBH that notes the authoritarian model amounts to “moral hegemony” by running roughshod over the perspectives of other relevant parties. The pure consensus approach sees the formation of agreement as the only responsibility of the ethicist. This approach is also not reflective of the field because it allows for the possibility of forming a consensus that overrides justified moral values. Rejecting these two extreme positions, the report recommends a facilitation approach where the job of the ethicist is to build consensus “within the bounds of ethical and legal standards” [10].

On this model, moral expertise amounts to knowing where the bounds of ethical standards lie. The ethicist does not normally declare what ought to be done, but sets the range of acceptable options. The facilitation approach is a modest form of moral expertise, but it is a form of moral expertise nonetheless. The ethicist must explain upon what basis they determine the bounds of acceptable ethical standards.

The skeptic’s arguments point to the problem of moral justification, but the alternatives they offer (radical skepticism or pure autonomy) merely end up exchanging one philosophical problem for others. While the arguments against moral expertise are

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strong, the necessity of doing ethics is stronger. Moral theory may be a quagmire, but it is a quagmire we cannot avoid.

Christine Korsgaard echoes the necessity of ethics in the opening line of her book SelfConstitution, which proclaims,“Human beings are condemned to choice and action” [12]. By extension, human beings are condemned to take positions on clinical ethics that go beyond mere skepticism and pure respect for autonomy. The moment one realizes the inadequacies of a pure autonomy approach, and sets about trying to discern when autonomy should be limited, one has already abandoned an ethic based merely on respect for autonomy for a more robust approach.

However difficult it may be to reach a consensus regarding a robust moral view, it is a conversation we are all forced to have. I therefore call on those skeptical of clinical ethics to give up on their mere skepticism and engage in the hard, unavoidable work of eshing out the moral domain of bioethics.

Endnotes (1) One of the major problems with arguments from disagreement is that there is disagreement about what conclusions follow from disagreement. If disagreement among ethicists is a reason to reject ethics as a domain of knowledge, and there are those who disagree that disagreement about morality leads us to reject ethics as a domain of knowledge, then it seems, by its own lights, we should reject the claim that disagreement in ethics leads to a rejection of the field. This is a general problem with such views about disagreement that has been well noted in the disagreement literature [5].

(2) This disagreement may be due to the fact that Fox et al. judged the guidelines “too nonspecific and nonprescriptive to suggest a particular best course of action” [6].

(3) In philosophy, this epistemological view is called evidentialism [Peterson,M.L.(2013).

Reason and religious belief: an introduction to the philosophy of religion, New York: Oxford University Press, [2013] 5th ed.].

Reformed epistemologists like Alvin Plantinga start from a critique of evidentialism to argue that we have some beliefs which we hold without further reasons and that belief in God can count as one of these “properly basic” beliefs [Plantinga, A. (2011). Where the conflict really lies: science, religion, and naturalism, New York : Oxford University Press, c2011.].

4. Engelhardt, H. Tristram. 1996. The foundations of bioethics. New York : Oxford University Press, 1996. 2nd ed.

(4) This is an old problem in philosophy that dates back, at least, to the skeptics of the Hellenistic period [Melchert, N. (2011). The great conversation : a historical introduction to philosophy, New York ; Oxford : Oxford University Press, 2011. 6th ed.]. It is called the problem of the criterion, or also the Münchausen trilemma.

7. Gesang, Bernward. 2010. Are moral philosophers moral experts? Bio- ethics 24 (4):153-159.

(5) For Engelhardt, the implications for this are profound. It must be admitted that even the most “obvious” of moral claims, such as “one should not torture and kill the innocent for sport” become without any rational basis [4].

References 1. Bambrough, Renford. 1967. Plato, Popper and politics: some contributions to a modern controversy. Views and controversies about classical antiquity: Cambridge, Heffer; New York, Barnes & Noble, 1967.

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5. Feldman, Richard, and Ted A. War eld.

2010. Disagreement. Oxford [England] ; New York : Oxford University Press, 2010.

6. Fox, Ellen, Frona C. Daskal, and Carol Stocking. 2007. Ethics Consultants’ Recommendations for Life-Prolonging Treatment of Patients in Persistent Vegetative State: A Follow-up Study. Journal of Clinical Ethics 18 (1):64.

8. Harman, Gilbert. 2007. Moral Relativism Defended. In Founda- tions of Ethics : An Anthology, eds. Russ Shafer-Landau, and Terence Cuneo. Blackwell philosophy anthologies: 26: Malden, MA : Blackwell Pub., 2007.

9. Ho, D. 2016. Keeping it Ethically Real. J Med Philos 41 (4):369-383. doi:10.1093/jmp/jhw010.

10. Humanities, American Society for Bioethics and. 2011. Core Competencies for Healthcare Ethics Consultation. Glenview, IL. 11. Iltis, A. S., and M. Sheehan. 2016.

Expertise, Ethics Expertise, and Clinical Ethics Consultation: Achieving Terminological Clarity. J Med Philos 41 (4):416-433. doi:10.1093/jmp/jhw014.

2. Cowley, Christopher. 2005. A new rejection of moral expertise. Medi- cine, Health Care, And Philosophy 8 (3):273-279.

12. Korsgaard, Christine M. 2009. Selfconstitution : agency, identity, and integrity.

Oxford ; New York : Oxford University Press, 2009.

3. Cowley, Christopher. 2012. Expertise, Wisdom and Moral Philosophers: A Response to Gesang. Bioethics 26 (6):337342. doi:10.1111/ j.1467-8519.2010.01860.x.

13. Moseley, Ray, S. Van McCrary, Ellen Fox, and Carol Stocking. 1994. Variations in Recommendations of Ethics Consultants.

United States, North America.

14. Rasmussen, L. M. 2016. Clinical Ethics Consultants are not “Ethics� Experts-But They do Have Expertise. J Med Philos 41 (4):384-400. doi:10.1093/jmp/jhw012.

15. Sco eld, G. R. 1993. Ethics consultation: the least dangerous profession? Cambridge Quarterly Of Healthcare Ethics: CQ: The Interna- tional Journal Of Healthcare Ethics Committees 2 (4):417-426.

16. Shalit, Ruth. 1997. When we were philosopher kings: the rise of the medical ethicist. New Republic (New York, N.Y.) 216 (17):24-28.

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Social Inequity in Health A MULTIFACETED APPROACH TO THE UNDERLYING SOCIAL DETERMINANTS OF HEALTH

BY JACOB LEE

Social Determinants of Health

Today, we live in a country in which the health inequality has never been wider.

The myth of the American Dream tells us that we live in a society that is always moving upwards and every citizen’s socioeconomic status is open to change.

Certainly, if this was the case, then the gains of a society would be shared fairly by all its members. However, all levels of health, ill- ness, income, and resources follow a social gra- dient: upper classes live longer and healthier lives than people in lower classes. Furthermore, it is important to note that health inequality is shaped by both determinants of health and equity. For the purpose of this essay, I will focus primarily on social determinants of health, or the circumstances in which people grow, live, work, and age and how social structures put in place to deal with illness are shaped by political, social, and economic forces. The social deter- minants of health that will be discussed in the rst half of this paper will include individual re- sources, neighborhood or community resources, hazardous and toxic exposures, and opportunity structures. I will then examine the social determinants of equity, or the systems of power that determine the range of social contexts and the distribution of populations into those social contexts. The second half will touch on the social determinants of equity which will include the economic system, racism, and sexism. In order to a ect the social determinants of health in a way to achieve improvement in population health, the solution must involve all aspects of society: government, civil society, local communities ,business, and international agencies [7]. Only if American society is able to address all of these determinants will we move towards large and sustained improvements in health outcomes and social justice to ultimately reduce health inequalities.

When we look at individual resources as a social determinant of health, we tend to look at the individual’s education, occupa- tion, income, and wealth. In “Action on Health Disparities in the United States,” Marmot and Bell [6] describe the relationship between socio- economic position and health. While it is true that income and wealth play large roles in determining the quality of life as well as the access to healthcare, Marmot and Bell assert “that social action should deal with the entire gradient, and all of society, not only with those at the bot- tom" [6]. For instance: in India, 76% of the male population lives on an income of $2 a day or less, and yet the average life expectancy for men in India is the same as for men in Washington, DC. This evidence may suggest that there is not a single determinant that solely contributes to this ever-increasing health gradient in the US [6]. Rather, emphasis should be placed on an indi- vidual’s education and how that impacts later occupation. Marmot and Bell point out that the Commission on Social Determinants of Health (CSDH) identi es early childhood development and education as accurate predictors of later success, particularly for those children who are “born to parents who themselves have low educational attainment” [6]. Thus, approaching it this way is important for the collective as well as individual empowerment so that job insecurity, unemployment, and poor working conditions may be approached from the root.

It has been well established that those who have a good education hold higher paying jobs and gain not only nancial security but also access to environmental conditions, which enable them to live in comfortable neighborhoods than those who may not have higher education or proper living environments [3]. In their article, “Class – The Ignored Determinant of the Nation’s Health,” Isaacs and Schroeder [3] examine how class affects attainment of certain occupations and the difference in success that people of color experience when compared to their white colleagues in the same occupation.

Since “employment is a key socioeconomic determinant of health” [3], Isaacs and Schroeder point out that jobs bring in not only income but potentially also status and prestige. On the other hand, lower status jobs provide work- ers with poor work environments, boring and repetitive tasks [3]. In addition to lower income gain, these occupations also provide little job security and control over the nature of their work, how long they work, and eventually leads to increased stress levels, which is known to increase the chance of illness [3].

These disparities in occupational benefit are further perpetuated by neighborhood (place-based) or community (group-based) resources in the realm of healthy behaviors and lifestyles [3]. Isaacs and Schroeder provide evidence that in the United States, people without high school diplomas compared to those with college graduates are“three times as likely not to engage in leisure-time physical exercise” [3]. Often this is a result in locations where public recreation is non-existent or exercising outdoors is dangerous [3].In addition, unhealthy lifestyles are exacerbated from unhealthy eating habits which often stem from unavailable wholesome food [3]. With the limited range of food choices leading to obesity and the lack of public outdoor safety and accessibility of recreation, it is no wonder that this characterizes lowerclass life. Less health insurance coverage, poor neighborhoods with low housing stock quality, and unhealthy dietary behaviors all increase the risk of premature death [3]. Thus, much attention is needed on the allocation of resources in a place- and group-based context.

Social Determinants of Equity Lower socioeconomic status also leads to people in rural communities to be exposed to more environ- mental hazards according to place, occupation, or group membership [7]. In the article “Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health,” Marmot et al. [7] describe the current model of urbanization and the challenges it poses to both developed and low-income societies.

From an availability standpoint, in the developed society, the reli- ance on cars and transportation has increased convenience and saves time, whereas in low-income societies, access to such transportation is not readily available [7]. Marmot et al. state that inconvenient“methods of travel have knock-on effects on taking in greenhousegas emission” [7]. Poor local air quality is an environmental hazard to those who do not have access to convenient transportation based on their place, occupation, or group membership. As a result, it is important to note that the planning and design of urban environments has a major role in health equity through its in uence in accessibility and environmental aspects. inally, concerning opportunity structures as a social determinant of health, I will expand on meaningful occupations, the quality of schools, and how equal justice should play in these two aspects. Marmot et al. assert that “work can provide nancial security, social status, per- sonal development, social relations, and self-esteem” [7]. As previously stated, an increase in stress leads to a greater chance of illness, specifically coronary heart disease. To this end, Marmot et al. propose that a central goal of employment policy should be aimed towards providing a living wage to protect all workers from harmful associations with low paying occupations [7]. Similarly, as for the quality of schools, there is sufficient data to show that early childhood development in areas of cognitive, social, emotional, and others, are necessary for good lifelong effects [7]. To build equity from the beginning of life, Marmot et al. propose strengthening existing child-survival programs, extending interventions, as well as providing “high-quality compulsory primary and secondary education for all children” [7]. Programs and interventions like these suggested by Marmot et al. have the ability to attack social determinants of health inequity at their root causes [7].

I will now address the social determinants of equity as the systems of power that determine the range of social contexts and the distribution of populations into those social contexts. In an editorial, Link and Phelan give an overview of the US economic system and how it creates a class structure through the private ownership of the means of production [5]. From a sociodemographic point of view, Link and Phelan look at patterns of disease and how they are useful for explaining the distribution of funds by the gov- ernment. It was discovered through their findings that people of higher socioeconomic status became more likely to quit smoking and less likely to start again [5]. This social link between economic and disease involves resources such as knowledge, money, and connections, and it is precisely these resources that enable economically well-off people to be less affected by disease [5]. So what are some structures or policies in the economic system that help determine the range and distribution of this social deter- minant of equity? I suggest corporate accountability may be a strong basis to build responsible collaboration between public and private interests. In addition, the outcomes of health should be considered in policy making regarding the regulation of goods which have major effects on health such as tobacco, alcohol, and food.

Racism, as another aspect of the social determinant of equity, structures opportunity and as- signs value based on the social interpretation of how one looks. Jones et al. [4] provide an interesting analogy that expands on the view that social biases heavily influence which and how much of certain goods people of color receive compared to their white counterparts. Many determinants of health are beyond individual

behaviors and genetic endowment.

Jones et al. observe that “these contexts are also not randomly distrib- uted, but instead are shaped by historical in- justices and by contemporary structural factors that perpetuate the historical injustices” [4]. They present the “Cliff Analogy” to serve as a guide to possible interventions to deal with the problem of people falling off a cliff of good health [4]. In one scenario, an individual falls off the cliff and there is a safety net and an ambulance to take them to receive quality medical care. However, in another community – or perhaps the same community – when someone falls off the cliff, their family members are the only ones to come see them broken at the bottom of the cliff. Jones et al. [4] encourage their readers to consider if there are health interventions that can play both direct and indirect roles in health equity notwithstanding social biases of how one looks. They suggest that policymakers can make use of their analogy to evaluate current health investments and encourage community leaders to widen their range of options on how health resources are spent. Only then, perhaps, the analogy can be completed where there is not only an ambulance waiting at the bottom but also a strong fence at the edge and the resources available to move the community away from the edge of the cliff.

Last, but not least, the final social determinant of equity concern I will discuss is sexism and how value is similarly assigned to gender.

Blacksher [2] addresses topics of health equity and the harms of misrecognition. She states the premise that “even population-based interventions can (re)produce health inequities...they tend to benefit more advantaged groups first and disproportionately because better-off groups are better situated to benefit from improved conditions" [2]. This is crucial to understand her concept of misrecognition, a form of disrespect that creates subordinated groups which are

often treated with stereotypes, shaming, violence, etc. [2]. The position of women in society is commonly associated with child health and survival in some societies [2]. Gender inequities influence health through violence towards women, lack of power, unfair work schedules or environments, and the freedom to improve one’s life. In con- sidering this, Blacksher asserts that“ respect has its value for any individual or group of individu- als only when the social conditions that promote and sustain it are equal for all" [2]. This norm of equal recognition can place ethical limits and ultimately reduce health disparities through governments, international organizations, and civil society.

Then, through this shared power in policy, communities and groups can work together to achieve equal recognition in gender and promote gender equity.

Discussion These multifaceted social determinants of health and equity can be well illustrated through a couple of real-world examples. After realizing that prescriptions and recommendations were not effective in changing patients’ health, Dr. Julian Perez realized that the family and other social factors within the home and the neighborhood are important factors that affect chronic diseases [8]. In order to successfully treat his patients, he recognized that he must look at the big picture [8].

Angela Garcia, in her novel “The Pastoral Clinic,” observes that the modern-day approach to help someone with a drug addiction involves education, medication, frequent visits, and valuebased care, all of which are good but miss the essential problems of poverty [1]. As Garcia recalls in her ethnography, she took a walk along the Rio Grande because she thought it “would provide a respite from the many challenges of clinic life” [1] However, upon finding syringes littered everywhere, she realized that New Mexico’s landscape sustains addiction and addiction, in return, shapes New Mexico’s landscape. Dr. Perez made a similar discovery, realizing that legal troubles shape health and that geographical location perpetuated poor health, resulting in addressing social determinants of health as really just dealing with poverty [8]. This realization led him to discover that a vast number of patients confessed to having legal problems when they were asked about legal problems. Once these problems are

identified, then strategies can be formed to give people good health, long lifes- pans, healthy children, and low death rates. Dr. Perez describes legal problems as “an equity issue of justice because there’s justice out there but it’s not equitably distributed... depends on which court district you live in, what is your situation when you get there, who presented your case, and folks who don’t have the means, money or time don’t necessarily get equitable care” [8].

This correlates and connects the lived experience of Hispanic addicts to the internal structure of institutions that create a “patient and prisoner” model, which is absorbed by the addict and exacerbates a sense of personal failure that in turn contributes to the regional heroin problem itself [1]. Many of the patients at the detox facility in New Mexico felt that their lives and struggles were “without end” and that their existence was defined by a constant state of suffering [1]. Garcia recalls a patient who was concerned with the arrangement of care and told Garcia that “the first thing you gotta do is get rid of all the heroin addicts in order to save one... otherwise we’re all just reminding each other of what we need” [1]. One motivating factor behind drug recovery is personal choice and the institutional policies in place were flawed in achieving exactly that among their patients. Even up to the very end, the closing of the clinic mirrored the experience of addicts: the dismissal by institutions that had the power to remake their lives, day-to- day instability, and feelings of vulnerability and failure [1]. Thus, intervening in social structures and attending to systems of power are crucial. Through this combined medical-legal approach, we may be able to help patients and their families have better care, better health, longer lives, and a better quality of life.

So where do we go from here?

If there is a genuine desire to change, to create a better and fairer world where life expectancy and health are not determined by factors outside of one’s control, then the answer is promising. The concept of health policy must be broadened beyond the health sector because education, recreation, transportation, and housing all contribute to the effect of health as we have seen. With a proper allocation of funding,

equity can be achieved in society. Society is a cooperative effort that humans can shape or reshape to meet their collective ends in terms of health. This is the “up- stream” issue that has the potential to produce favorable communities, opportunity structures, and individual resources on a large scale.

Upstream issues in society and systematic differences in socioeconomic class, race, and gender, play important roles in

the pursuit of health. In fact, many issues are preventable through collective action on these social determinants of equity. With this knowledge and the means to change at hand, a nation that is serious about improving the health of its people must have this longterm agenda in mind and ultimately the willpower to change for the responsibility that so greatly rests with us.

References [1] Angela, G. The Pastoral Clinic: Addiction and Dispossession along the Rio Grande (United States: University of California Press, 2010).

[2] Blacksher, E. “Redistribution and Recognition: Pursuing Social Justice in Public Health” Cambridge Quarterly of Healthcare Ethics 21 (2012): 320-331.

[3] Issacs, S.L. and Schroeder, S.A. “Class: The Ignored Determinant of the Nation’s Health” The New England Journal of Medicine 351 (2004): 1137-1142.

[4] Jones, C.P., Jones, C.Y., Perry, G.S., Barclay, G., and Jones, C.A. “Addressing the Social Determinants of Children’s Health: A Cli Anal- ogy” Journal of Health Care for the Poor and Underserved 20 (2009): 1-12.

5] Link, B.G., and Phelan, J.C. “Editorial: Understanding Sociodemographic Di erences in Health – The Role of Fundamental Social Causes” American Journal of Public Health 86 (1996): 471-472.

[6] Marmot, M.G., and Bell, R. “Action on Health Disparities in the United States: Commission on Social Determinants of Health” Journal of the American Medical Association 301 (2009): 1169-1171 [7] Marmot, M.G., Friel, S., Bell, R., Houwel- ing, T.A., and Taylor, S. “Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health” Department of Epidemiology and Public Health, University College London, UK 372 (2008): 1661-1668.

[8] Perez, J.C. “Health Professionals as Advo- cates: Using the Legal System as Health Pro- fessionals to Protect and Advocate for Migrant Farmworker Health” (book series presented at UW Health Sciences Common, Seattle, Wash- ington, November 19, 2016).

CHRISTINA GALIANO

In this paper I will assess the benefits and downfalls of using quality adjusted life years (QALYs) in healthcare decisions. I will focus on two specific uses of the QALY. I will argue that QALYs can be useful when comparing the cost effectiveness of two or more treatments, but are neither adequate nor ethical in the process of allocating healthcare resources in cases which call for assessing and making decisions about who should obtain life-extending medical treatments over others, based on their medical conditions. I will also argue that a main flaw of the QALY is that it only takes into account two measurements — quality of life and quantity of life —and that these gauges are inadequate in assessing life’s value, as can be seen in various medical treatments and in our society’s beliefs about life, illness, and death.

Using QALYs can be beneficial in some realms of health care—such as in weighing two treatments against each other—but not in allocating lifesaving or life extending treatments between individuals. The QALY is a system that takes into account quality of life, using a rating of 0-1, and quantity of life in years by multiplying these two numbers together to assess the value of a certain medical treatment or the benefit that attaining a medical treatment would have on one’s life [1].

For example, 5 years of life in perfect health are 5 QALYs because quality of life is equal to 1, but 5 years of life at a 0.5 assessment of quality of life equals 2.5 QALYs. QALYs are thought to be a particularly attractive tool in health care because “..,the QALY combines changes in morbidity (quality) and mortality (amount) in a single indicator... QALYs are easy to calculate via simple multiplication... [and] finally, QALYs form an integral part of ... economic analysis within health-care, i.e. cost-utility analysis (CUA) [2].”

The simplicity and apparent accuracy of QALYs demonstrates their appeal.

This system can be beneficial in weighing two treatments or interventions against each other.

For example, if a pharmaceutical company were to weigh two potential cancer treatments to be marketed against each other, using the QALY would be favorable. If one treatment has many undesirable side effects and will only extend life by a few months, the value of it is less than a treatment that has few undesirable side effects and will extend life by years. QALYs are even more useful when analyzing two treatments in a more complex manner—perhaps one treatment has many undesirable side effects and is known to lower the quality of life for any patient who takes it, but can extend life for many years, while

another has more modest side effects but will not extend life as long. The more beneficial treatment in this scenario is not as readily obvious and it is useful to use a system like the QALY to weigh two treatments against each other. In this situation, one is weighing the importance of quality of life with quantity because these are the two factors that a treatment will likely impact. QALYs are useful in this instance and ask us to consider what is valuable about life during an illness and worth paying for in a treatment. In this situation, a reasonable solution can feasibly be reached after much introspection on what patients with a certain disease value about life given their prognosis.

Now that I have pointed out a useful way that QALYs are used, I will argue that QALYs have major downfalls in some of the tool’s other uses.

In the remainder of my paper I will argue that the use of QALYs to allocate a limited resource such as a life saving treatment to certain people, or in other words to use the system to weigh two people’s lives against each other, has reprehensible flaws. The key difference is that using a numerical system to assess two treatments or interventions, substances used to ameliorate illnesses, is quite different from weighing two people’s actual lives against each other. In the case of weighing two treatments against each other, a useful outcome can presumably be reached in declaring that one treatment is superior over another. It is true that everyone involved, every doctor or patient or pharmaceutical company, might not agree on the verdict about the two treatments, but given the facts and given a persuasive argument as to one treatment over another, a practical judgment could be reached.

However, if QALYs are used to allocate resources like life saving treatments to certain people, they are being used to assert that one person’s life is superior to another’s. This idea diminishes the right to life and autonomy that people, even the severely ill, should have. In this situation, numbers do not seem adequate to capture the complexity and intricacy of someone considering the value of obtaining a life saving treatment, and by proxy, the value their own life, especially in relation to others, as I will explain.

I will continue my argument by criticizing using QALYs to allocate resources in order to decide who should obtain a medical treatment. One of the main flaws in using QALYs to decide which patients should get important medical treatments is that its value is compromised in considering the lives of those with disabilities. In Peter Singer’s “Why We Must Ration Health Care,” he argues that we can use QALYs to assess the value of giving someone a medical treatment that will extend their life in a compromised condition, like quadriplegia, compared to treatment extending the life of someone in better health [3]. In this, he concludes that the more valuable treatment would be one that extends the life of someone in better health because of their superior quality of life, which goes into the QALY measurement [4].

He argues that this is a clear choice to make and does not infringe on the right of life of those with disabilities because many people with disabilities themselves, would pay exorbitant amounts to fix their conditions, therefore implying that they concede that their life with the disability is worth less than their life without it [5]. Singer states, “If life with quadriplegia is as good as life without it, there is no health benefit to be gained by curing it...

Disability advocates, it seems, are forced to choose between insisting that extending their lives is just as important as extending the lives of people without disabilities, and seeking public support for research into a cure for their condition [6].”

This idea is pervasive in the logic of using QALYs to allocate treatment because the assumption is that someone’s current or potential quality of life will be weighed against another persons in order to decide who may live or die.

However, a major flaw in Singer's argument, and in the logic of using QALYs to allocate treatment is the assumption that because a quadriplegic or anyone with a chronic and inopportune health condition, would like to better their condition given the chance, this is tantamount to stating that they find their life with the condition less valuable than another healthy life. Along this line of reasoning, Singer would believe that rationally, someone with quadriplegia should condone sanctioning a non-disabled person to receive a life extending intervention over them, because they

themselves have expressed that their health condition makes life worse. But it is a misconception that because someone would like to make a change to better their quality of life, they view their current life with a disability or potential life with a disability as less valuable and less deserving of a life extending or life saving treatment and would concede that their living with a disability is equal to death itself, given those two options. This is essentially the choice that Singer is forcing upon such a disabled person by expressing this “problem” in the situation of allocating treatment to a disabled and non-disabled people.

His argument confuses the ideas of wanting a better life and living with a satisfactory but disabled life and reduces what goes in to considering quality of life.

The idea of someone making such a choice can be seen in everyday life: Consider an example of someone who is unemployed and is applying to jobs and desperately needs an income for the necessities of life. They have two job options, no other options available to them, and no more time available for their job search. One job is an ideal opportunity for them—it is work that seems enjoyable, greatly interests them, and pays very well—while the other job is an admittedly worse option. The second job is more mundane, harder work, and does not pay well, but pays enough to stay afloat. Now suppose that person is to decide between the two options, but for some reason the first option is no longer available to them. It is rational to think that they would choose to work the job that is a second choice over choosing to persist as unemployed and struggle for the necessities of life and would thus see inherent value in working this job. After all, a job is a job.

While this example is not an immediate life or death option like it is for a life extending treatment for the quadriplegic vs. a healthy person, the stakes are also high in such an example and it can be useful to consider why one would choose an admittedly worse option and still see merit in this choice. This example demonstrates the fact that someone can simultaneously and rationally strive for an ideal option, but still see value in an option that is worse when compared to the third bleak alternative and it does not diminish that option’s value. When considering an ideal job and a less preferable job, or a perfectly healthy life and life as

a quadriplegic, the fact that one would prefer the ideal job or a healthy life does not mean that they do not see any value in the “worse” options. In colloquial terms, when someone is making a decision, they are likely to think that one option, even if it is not their first choice, is “better than nothing.” a worse option, to having “nothing.” If Singer persists with his claim, he is likening living with a worse option, to having “nothing.”

Paul Menzel expresses the same idea in "Allocation of Scarce Resources" by assessing a situation in which a life saving treatment can either go to one who will be a paraplegic or one who will be completely recovered [7]. According to QALYs and Singer’s line of reasoning, if the treatment will extend life for both of them by similar durations, then the treatment should go to the person who will be fully recovered because their quality of life will be better. Obviously, the quality of life for a paraplegic would be worse than that of a fully healthy person, and they would have countless difficulties to face in their condition, but compared with death, their life and potential to be saved should be weighed as equal to any other persons. Menzel writes from the view of the paraplegic person, saying “you do not admit—and you never have admitted—that when life itself is on the line, a life with paraplegia is any less valuable to the person whose life it is than life without that disability would be to someone else [8].” He goes on to say, “compared with death, your paraplegic life would still likely be as valuable to you as anyone else’s better life is to them [9].” This idea is what Singer fails to acknowledge when he points out the apparent hypocrisy of someone with a disability simultaneously wanting a surgery to improve their condition and also expressing that their disabled life is worth as much as a fully abled life. A person who wants to improve their condition may be admitting that a fully abled, healthy life is preferable to their condition, but compared with death, their disabled life is worth just as much as any other life.

Life itself is full of people wanting to better themselves and improve their condition and it should not be considered fallacious for disabled people to do so as well and still contend that their life is worth as much as a healthy life. In another example, if someone is living with a chronic disease, such as Chron’s disease (a commonly painful condition that likely lowers the quality of everyday life) wants to get medication to better their quality of life, they are not implicitly expressing that their life with Chron’s disease is not worth as much as a life without it. They simply do not want to live with the pain and difficulty of their condition if there is any other choice. The person with Chron’s disease and the paraplegic or quadriplegic are coming from vastly different baselines of health, but all of them striving to better their condition does not mean that they believe that their life with the condition is of less worth.

Another important distinction to make is that when people use QALYs to allocate resources, they presumably would ask a patient to assess how much their quality of life with a condition is worth and how many years of healthy life they would trade compared to years with their ailment to gauge their values. In doing this, one is thinking about one’s own life and death and not comparing it to someone else’s. Life and health itself are very subjective experiences and in making such assessments people are delving deeply into what they value about their life. However QALYs use a subjective assessment of someone’s own life to weigh lives against one another in an objective and calculating manner. It is likely that if a doctor is asking someone to weigh their quality of life with an illness and tells them that their assessment will be used to decidewhether they or another person will receive a life saving treatment in the future, people would think about their QALY rating very differently and rate their projected quality of life higher in order to save their own life.

A proponent of using QALYs to ration treatment would likely object that if someone is thinking about their own life and death, then it is a fair and unbiased way to gauge how they feel about the benefit of a treatment and this unbiased assessment should be used to allocate treatment.

To this I would argue that the consequences of

what is to happen by using QALYs—allocating a treatment to a limited number of people or between two people—is of the utmost importance. If people are to rate the value of their existence using a scale from 0-1, they should have a right to know what the result, (the QALY) is going to be used to assess. In the situation of someone who does not know that their QALY rating will be used to allocate resources between them and another person, they likely believe that this number is always going to be used in their best interest and used to decide what treatment or medical option is best for them alone.

They are choosing a number between 0 and 1 that reflects how they feel about three things: their healthy life, life with their medical condition, and death. These three factors are subjective experiences to a person who is unaware that the number may justify them not receiving a treatment because someone else might have a higher number.

In contrast, in the situation of a patient knowing that their QALY assessment will be used to weigh their life against another person’s, they are choosing a number that now reflects their beliefs on four factors: their healthy life, life with their medical condition, death, and the value of someone else’s, but the QALY system ignores this discrepancy. If we grant that it is a known certainty that people inherently value their own life more than a stranger’s, then the fourth factor that goes into deciding on a number when the patient is fully aware of what will happen with that number, renders the QALY inaccurate in this situation.

Contemplating why it is different to consider one’s own life and one’s own life in relation to someone else’s is akin to my case criticizing Singer’s argument about the quadriplegic. The quadriplegic is likely to value a healthy life over their disability, but not someone else’s healthy life over their life entirely.

Another crucial attack on using QALYs in health care has been articulated by John Harris in his piece,“QALYfying the value of life [10].” Harris brings up yet another powerful flaw in using QALYs for disabled people or people with an admittedly compromised quality of life, which he calls “double jeopardy [11].” Harris explains this problem by claiming that “QALYs dictate that because an individual is unfortunate, because she has once become a victim of disaster, we are required to visit upon her a second and perhaps graver

misfortune [12].” The “misfortune” that Harris brings to light is the idea that such a person is suffering yet another impediment by automatically being at a disadvantage in obtaining a life saving treatment in the QALY system [13]. Harris goes on to say, “the first disaster leaves her with a poor quality of life and QALYs then require that in virtue of this she be ruled out as a candidate for life saving treatment, or at best, that she be given little or no chance of benefitting from what little amelioration her condition admits of [14].” Exposing the problem of double jeopardy for the disabled augments my criticism of using QALYs to allocate life saving treatments in that such an argument appeals to our idea of fairness as human beings. The idea that Harris brings to light in using the term “double jeopardy” likens a disabled person being at an inherent disadvantage to fully abled people, to one being tried or punished for the same crime twice [15]. The idea that a disabled person should not be “punished” again for their misfortune by being at an automatic disadvantage in the allocation of resources is in line with using justice to guide healthcare decisions.

In “Double jeopardy and the use of QALYs in health care allocation,” Singer et al. object to Harris’s idea of double jeopardy and defend the QALY by arguing that it is not necessarily unfair to give less of a priority to a disabled person because of the idea of “interest in continued life [16].” The authors define “interest in continued life” as a “measure of the value that continued life holds for the person whose life is at stake,” an idea akin to the quality of life measurement in a QALY [17]. Singer et al. argue that in considering allocating treatment to two patients, one of whom is disabled, there are only two options: allocating treatment to neither person and thereby allowing them both to perish, or using a method to select one of the patients [18]. At face value, this idea seems reasonable—most people would agree that it is more favorable to save one of the people rather than allowing both to die. But the idea that is worrisome in using such an argument to justify using QALYs is in deciding what kind of method to use. Singer et al. state that one could consider using random chance to decide who gets the treatment, however using random chance “...would in turn seem less attractive than a method of selection that gives preference to the person with a stronger interest in continuing to live...if they

choose a random method of selection in order to avoid discrimination... then some with a higher interest in continued life will not receive such treatment [19].” The flaw in such an argument defending QALYs is in the idea of weighing two people’s interest in continued life.

The problem with Singer et al.’s defense of using QALYs to allocate life saving treatment, and thereby conceding less priority to those with a lower quality of life (given that quantity of life left is about equal) is that the authors, much like Singer’s prior argument regarding disabled people, fail to acknowledge that a disabled person, while having an admittedly worse quality of life, will likely value their own life as much as a healthier person would [20]. Much like I have discussed, the fact that a disabled person may admit that their life with the disability is of less quality than their healthy life, when compared with death and when comparing two lives against each other, the disabled person does not have a less valuable life.

In fact, in an influential psychological study of the happiness of disabled people, called “The life satisfaction of nonnormal persons,”researchers studying happiness levels discovered that healthy people and disabled people do not differ on this account [21]. The results of this study elucidated that, “no differences were found among the dimensions of life satisfaction, frustration with life, and mood, while some evidence indicated that the handicapped were less suicidal, more religious, more oriented toward the generalized other, and felt their lives were more difficult [22].” These results reinforce my argument that the life of a disabled person compared to that of a healthy person is not less valuable because of their compromised quality of life. Such a study shows that human beings have a remarkable ability to adapt to their circumstances, and while a healthy person may consider the life of a disabled person and think that it must be less valuable because of the difficulties that come with such a life, a disabled person may consider their own life as one that is undeniably more difficult, but because they have adapted to their circumstances and found a new “normal,” their life is just as valuable as someone else’s. It is not as easy as Singer et al. suggest to judge the value of someone’s life from the outside and gauge how they would see their “interest in continued life.” Since “interest in continued life,” and the similar quality of life measurement in QALYs are prone to such flaws, it is

not a suitable system to allocate life saving resources among patients.

I will now argue that part of the logic behind using QALYs in health care is problematic because QALYs take into account only two factors: quality of life and quantity of life. Only considering these two measurements greatly oversimplifies the value of life.

The notion behind assessing quality of life as less than 1 when there is illness or disability involved allows us to deduce that, in this line of thought, when the quality of life is lower, the value of life is lower. In turn, using the quantity of life measurement leads us to think that life is less valuable when there is less of it left. Amount and quality of life are not both of extreme importance in considering the value of life, but our healthcare system and much of our thought as a society behind life, illness, and death, asserts that this is not always true. If this is not always and consistently true, then perhaps a better system or a similar system that takes other factors besides these two factors alone into account should be used instead of QALYs. If we assess the two factors of QALYs separately, quantity of life and quality of life, we find that elucidating the value of life in relation to each of them alone is not always clear. In other words if life’s value consists of the quality and quantity of life, as the QALY measurement alleges, then it is sensible to think that if the quality of life is low or not existent, or if the quantity of life left is short, then there is little value in one’s life. I will first delve into why quantity of life left is not always a good measure of the value of life, and then argue the same for quality of life.

In our society, people still see value in life even when the quantity of life left is extremely low and death is imminent. According to the Journal of the Royal Society of Medicine, “end-of-life care accounts for about 10-12% of all healthcare spending. Annual expenditures for hospice and homecare—two healthcare segments that are closely involved in the provision of end-of-life care—are about $ 3.5 billion and $ 29 billion, respectively [23].” The fact that we, as a society, spend a substantial amount of money on end of life care means that we value life even when one might be bedridden and have a shortly impending and inevitable death. Exorbitant amounts of money are spent to sustain life even if only for a limited amount of time, showing that people see value in life

even when they know they are only prolonging life by a short amount of time. As is noted in “The Cost of Dying,”“... Medicare...will pay $55,000 for patients with advanced breast cancer to receive the chemotherapy drug Avastin, even though it extends life only an average of a month and a half; it will pay $40,000 for a 93-year-old man with terminal cancer to get a surgically implanted defibrillator if he happens to have heart problems too[24].” It is important to note that people’s actions and choices about how to spend money end up reflecting their values in times of adversity, such as in deciding how to spend money on cancer treatments. Considering these Medicare expenses demonstrates that our society insists on paying for an expensive life prolonging treatment even when the QALY value for the quantity of life measurement is negligible. If the quantity of life left is a sufficient measurement of the value of life, then our society would not be spending such amounts to prolong life by such an insignificant amount of time, but such facts show that this is not the case.

It is evident that the relief of pain and suffering during one’s final months and delaying death even by a short amount is of importance to us as a society. This is reflected in the quality of life measurement of QALYs. In using QALYs to gauge the value of life, if two patients both have a simi lar diminished quality of life, when there is only six months of life left for person, this life is less valuable than a life with a little over a year left.

However, if it were someone’s mother or spouse who was in end of life or nursing care with six months left, it is likely that they would not think that their family member’s life is worth less or less deserving of resources than anyone else’s. They would likely ght for their family member to have just as good, if not better, end of life care than anyone else, even if they have less time left. Using QALYs to reflect life’s value demands that someone try to view the value of that life objectively, but realistically most people would not be able to view the value of their life or their loved one's life objectively. Reflection of such a situation and the prior facts about health care and Medicare expenditures illustrate that there is more to the value of life than the quantity of life left.

There are also instances in healthcare where we, as a society, greatly value quantity of life, or just being alive, even when the quality of life is low. This shows that we value life even when there is very little good quality to it. For example, many people are kept in a minimally

conscious or vegetative state, even when doctors imply that the prognosis is poor. In this state, there is virtually no quality of life, because there is little or no awareness or brain activity. That people are kept alive at all in this state implies that for some, the fact that they are technically still alive has value over being dead. The QALY measurement for such a person would be extremely low and difficult to figure out because people can usually persist in this diminished state for an unknown length of time. Thus, a quality of life measurement is not always a good way to asses the value of life.

A critic of my argument may contend that the fact that people are kept in this state for long periods of time does not necessarily mean that people value life with no quality measurement, but that people are typically kept in this this state out of hope that they will recover, or that a miracle will occur. To this objection, I would argue that while hope may play a large factor in keeping people alive in a diminished state, it does not render my point erroneous. The fact that people’s relatives who keep them in this state make an in the moment and day-to-day judgment to keep them alive over letting them go, means that they believe that being technically alive, with little or no quality of life, is greater than being dead in that moment, regardless of the future.

The future in this situation is uncertain—they may or may not regain consciousness, but the situation in the moment is clear—they are in an extremely diminished medical state where there is little or no quality of life.

Furthermore, this judgment—of valuing simply being alive or quantity of life over quality—is seen in many other aspects of health. For example, in a case when someone is diagnosed with Alzheimer’s, which has no cure and which diminishes quality of life in that people essentially lose who they are and everything that their life has meant to them, it would be considered cold and heartless to say that their life has no value. While this case is less extreme than the case of one in a minimally conscious or vegetative state, it is still a tragic event when someone is diagnosed with Alzheimer’s because they and their loved ones know that their life will undergo great and dreadful changes. Their quality of life is greatly lessened by having this disease, but numerous people live many years with Alzheimer’s, rather than they or their loved ones proclaiming that life is not at all worth living with this prognosis and simply giving up. This case shows that people still value life when the quality is either non-existent or greatly worsened. Exposing some of the flaws in considering quantity of life or quality of life as the only aspects of what makes life valuable discloses

some of the problems behind the logic of QALYs. It seems as if there is something about life, some unexplainable value to it, that measuring quality of life or quantity of life are incapable of capturing. If neither of these two factors completely elucidates the value of life, then there must be more that goes into assessing life’s value.

In this paper, I have argued that QALYs can be useful in comparing two treatments against each other, but it is not useful or ethical to use QALYs to weigh two people’s lives against each other in order to gure out how to allocate limited resources, such as a life saving treatment. I have also exposed flaws in the assumption that the combination of quality and quantity of life are what goes in to the value of life. The value of someone’s life is a very introspective issue that only they themselves can glean, and that a numerical system consisting of two measurements cannot completely evaluate.

Perhaps a better measurement of life’s value can be seen in assessing these two factors plus a variety of other subjective beliefs that a person has about themselves such as: their religious beliefs or any other belief system, the comfort or apprehension they have in dying, their relationship to their loved ones and how much they value what their loved ones think, their hopes for the future or life plans, and their conception of what makes them happy and what makes their life worth living. Perhaps a person cannot easily consider all these things and give it a numerical rating that the QALY measurement requires. As I have demonstrated in exposing the flaws of the logic behind QALYS, there is seemingly something inexplicable to the value of life. It is undeniable that resources in health care are commonly scarce and it is very reasonable to want to come up with a simple and effective system that can easily evaluate who should obtain certain resources, but the QALY measurement is not the answer.

References [1] Cameron, Paul, Donna G. Titus, John Kostin, and Marilyn Kostin. “The life satisfaction of nonnormal per- sons.” Journal of Consulting and Clinical Psychology 41, no. 2 (1973): 207-14.

[2] Court, Andy. “The Cost of Dying.” CBSnews.com.

Last modi ed November 19, 2009. Accessed December 31, 2016. http://www.cbsnews.com/news/the-cost-of-dying/.

[3] “Double Jeopardy.” Merriam-Webster.com.

Accessed December 31, 2016. https://www.merriam-webster. com/dictionary/double jeopardy.

[4] Harris, John. “QALYfying the value of human life.” Journal of Medical Ethics 13, no. 3 (1987): 11723.

[5] Menzel, Paul. “Allocation of Scarce Resources.”

Blackwell Guide to Medical Ethics, December 2006, 305- 22.

[6] Prieto, Luis, and José A. Sacristán. “Problems and solutions in calculating quality-adjusted life years (QA- LYs).” Health and Quality of Life Outcomes 1, no. 80 (December 19, 2003).

[7] Raphael, Carol, Joann Ahrens, and Nicole Fowler.

“Financing End-of-Life Care in the USA.” Journal of the Royal Society of Medicine 94, no. 9 (September 2001): 458-61.

[8] Resnik, David B., and Gerard Roman. “Health, Justice, and the Environment.” Bioethics 21, no. 4 (2007): 230-41.

[9] Singer, Peter. “Why We Must Ration Health Care.” New York Times, July 19, 2009, 1-8.

DOES IT HURT OR HELP MEDICAL PRACTICE?

BY SASHEENIE K. MOODLEY

"SO MUCH OF MEDICINE IS BASED ON HUMAN CONTACT, READING PATIENTS’ EXPRESSIONS AND BODY LANGUAGE.WE RISK LOSING THE HUMAN IDIOSYNCRASIES INHERENT IN THE MEDICAL REALM IF WE REPLACE EVERYDAY PRIMARY CARE WITH TELEMEDICINE."

A STORY OF

by Maggie Cleary

PERSONAL IDENTITY AND ADVANCE DIRECTIVES

" CHANGING, AS WELL AS DETERIORATION, HAS BECOME AN ESSENTIAL PART TO THE HUMAN CONDITION, AND IT SHOULD NOT BE WRITTEN OFF Â AS IRRELEVANT OR NONEXISTENT. "