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Distributive justice

Gaia Doesn’t Care where your Baby Comes From

25 Jul, 14 | by Iain Brassington

Guest Post by Dominic Wilkinson, Associate Editor, Journal of Medical Ethics

In a provocative paper published today in the Journal of Medical Ethics, US theologian Cristina Richie argues that the carbon cost and environmental impact of population growth in the West should lead to restrictions on artificial reproduction.  She points to the substantial carbon emissions that result from birth in developed countries like North America.  Seven percent of the world’s population contribute fifty percent of the world’s CO2 emissions, and children born by in vitro fertilization are likely to be in this seven percent.  Richie argues in favour of a carbon cap on artificial reproduction and argues that IVF should not be funded for women who are “biologically fertile”.

Richie is correct to point to the enormous carbon cost of additional human population. One of the most significant ways that individuals in Western countries can reduce global carbon emissions is by having fewer children. However, her focus on artificial reproduction and on the “biologically fertile” is not justified.

Richie ignores questions about the moral implications of climate change and climate cost for natural reproduction.  She sets to one side “the larger realm of sexual ethics and procreation”.  Yet there are two reasons for thinking that this is a mistake.  First, as Richie notes, “Reproduction-related CO2 is primarily due to choices of those who have children naturally: a huge majority of all births.”  Only 2% of all children born in the UK are conceived by IVF.[1]  Therefore interventions to reduce the number of children naturally conceived will potentially have a fifty fold higher impact on carbon emissions.  Secondly, it is profoundly unjust to apply restrictions to reproduction only on those who are unable to conceive by natural means.  It could be justified to limit the reproductive choices of women because of concern for the environment.  However, if this were justified, it would be equally justified to try to limit the reproduction of the naturally fertile and the naturally infertile.  It is ad hoc and unfair to confine our attention to those who must reproduce artificially.

Second, Richie proposes that public funding for IVF be confined to those who are “biologically infertile”, excluding same sex couples and single women.  However, she provides no reason at all for restricting the availability of IVF for these women.  Put simply, the carbon cost of artificial reproduction is exactly the same for a woman who is infertile because of endometriosis or polycystic ovary syndrome or because she does not have a male partner.  The only possible reason for making a distinction between biologically infertile and biologically fertile women is because Richie believes that lesbian and single women are less deserving of public funding because of their lifestyle choices.  However, that argument, as problematic and contentious as it is, is completely independent of the question of environmental impact.  The carbon cost of children born to gay couples is likely to be exactly the same as the carbon cost of children born to women with endometriosis.

The carbon cost of additional births might well be sufficiently important for the state to justify limiting reproductive freedom.  However, if the state is going to interfere in couples’ decisions about whether to have children or the number of children that they have, it should do so fairly and equally.  Carbon caps should be applied equally to those who conceive naturally and those who require artificial reproductive treatment.  They should not be used as a way to discriminate against those who are single or gay, or have some other ‘undesirable’ characteristic.

 

[1] http://www.hfea.gov.uk/ivf-figures-2006.html#1284

Enhancing the ill: The therapy-enhancement…

16 Nov, 12 | by David Hunter

This post is in effect a gauntlet, a challenge for those who are significantly bothered by enhancements, such that they think that enhancing would be unethical or at least that there is a significant ethical difference between the two, largely because I can’t really work out what the fuss is and would like someone to try and explain to me what worries them about enhancements and whether it applies in this case.

Therapy is usually distinguished from enhancement in the following manner – therapy is about restoring normal functioning whereas enhancement is about going beyond normal functioning. So for example I’m an asthmatic and sometimes I am prescribed steroids to enable my lungs to regain normal functioning. However if an otherwise healthy athlete took the same medication it would function as an enhancement, boosting them above normal performance.

Objectors to enhancement typically argue that there is a morally relevant difference between therapy and enhancement in that there are medical justifications to provide therapies on the grounds of justice/rights/equality but not enhancements. Hence there is a moral distinction because the state is obliged to provide (some) therapies but not, or at least the argument goes, enhancements.*1

And some commentators further argue that enhancements are unethical because of an array of reasons such as justice, risks, meddling with human nature and so on.

I want to suggest there is at least one class of enhancements where there is a solid medical justification to provide these. This is when something acts as both a therapy and an enhancement for someone – I’ll call these therapy-enhancements. A case will make it clearer which I’ll refer to as the Pinky & the Brain case.

Suppose we have someone who we will call Pinky who has a profoundly low IQ – let’s say 40, so low that they require substantial levels of state support to be able to live their life. Suppose there is a new drug A on the market that will increase the IQ of those with profoundly low IQ’s (and only those with these IQ’s) however it will increase their IQ’s significantly above species normal IQ levels of 100 to let’s say 160, hence transforming Pinky into Brain.*2 This seems to me to be a drug which is both providing a therapy since it raises them to a normal IQ and enhancing them as well since it raises them substantially beyond a normal IQ as well. If this drug is relatively speaking affordable – more cost effective than any present treatment they are getting then it seems to me obligatory that the state provide this despite it being an enhancement.*3

So this raises worries about how strong objections to enhancement can be, since if they are strong one might think we ought to forgo therapies that also enhance, which would seem to me to be unjust. We can strengthen this concern by considering a further case which raises questions for the strength of any morally relevant difference between therapy and enhancement.

Suppose that the pharma company who developed A, recognising the concerns some have about enhancement have developed a new drug B which like A raises the IQ of those with profoundly low IQ’s but unlike A it only raises them to the species norm of 100 – unfortunately due to the additional development costs, smaller market etc the company decides to charge twenty times the price of A. What should the state do, should it switch to B to avoid enhancing? I think clearly it ought not, and for me at least that intuition holds true until B is cheaper than or perhaps equal to A in price (in which case I’m vaguely indifferent but probably lean towards the free additional 60 IQ points). What this seems to show is that any normative force the distinction has is at best quite weak, easily over ruled by a slight increase in efficiency.

This doesn’t of course show that there is no morally relevant difference, merely that if there is one it is quite, quite weak.

*1 Of course this might be challenged since some things that look like things health care systems ought to provide such as vaccines seem to function more like enhancements than therapies.

*2 I’ll leave it up to you whether this increase in intellect induces what this lovely book (Soon I’ll be Invincible) refers to as Malign Hyper-Cognition Syndrome…

*3 Are there actual cases like this? I suspect the answer is probably yes – for example if a disabled athlete runs faster with their blades than they did before losing their legs this would be a case of a therapy-enhancement.

Junk food feeders are criminal child abusers? Really?

15 Oct, 12 | by David Hunter

Public Service Announcement: Sensitivity Advisory Sticker – Caution Post contains sarcasm.
In the interests of our more sensitive readers not taking offence I recommend they skip this post on the grounds that it will contain gentle sarcasm, disagreement and a certain amount of me asking “Is that really what they mean to say?”*

Blog Post:
The Oxford Practical Ethics Blog is typically very good, hence when there are posts that seem shall we say not quite as thought through as they might be it seems worth mentioning this and raising some debate. Presently Charles Foster has an interesting post: Should you be prosecuted for feeding junk food to your child?

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Why philosophical theorising about distributive justice in health care (mostly) doesn’t work

28 Jun, 12 | by David Hunter

I had the pleasure yesterday at the IAB 2012 to see Daniel Wikler run a symposium on population level bioethics – which primarily focused on prioritisation decisions. This was useful for me since it helped me coalesce why I think many if not all attempts to give a philosophical account of distributive justice in health care (and perhaps more generally) are doomed to fail. The methodology that Wikler et al adopted was to give a variety of cases which were in his words designed to isolate one element of tension for example fair chances vs efficiency so that we could evaluate and become more clear about what we value and why.

Now I don’t want to suggest such an approach is worthless – I do think it can help clarify what we think is and isn’t important, clarify concepts and so on. However much of the content of the symposium was similar to a symposium run by Wikler et al at the 2006 IAB in Beijing and for those of us who had attended both there was a sense that things hadn’t moved on much since then. I say that with no disrespect intended to Wikler et al – distributive justice in health is notoriously had and intractable so a lack of much progress is no sign of a lack of quality.

One of the cases they pulled up was interesting because it was iterative in nature – in the first case you have enough money to either vaccinate the 800 people who live in the city or the 200 people who live in the mountains. The majority of the audience chose the obviously efficient option. Then more money becomes available and you can now either vaccinate the remaining 200 in the mountains against that disease or vaccinate the 800 in the city against a new equally nasty disease. In this case Wikler reported that the majority of people they show the case to want to vaccinate those missed out in the first round which is puzzling since it is basically the same decision as in the first case but the opposite option is selected.

I think this case is useful to point out some flaws in this methodology and indeed in many approaches to distributive justice in health care. Taking isolated one off cases is of limited use because they make health care decisions too easy, health care decision making is (as I’ve argued elsewhere) inherently iterative if we spend money now to save X then that is likely to generate more health care needs and hence costs from X in the future. Hence decision making in health care prioritisation is embedded in time, and cannot be easily separated from its downstream impacts. As I’ve argued here: in regards to new technology this is unhelpful as a way to approach impacts. As I’ve argued here in regards to new technology this is unhelpful as a way to approach thinking about distributive justice because it prioritises justice at a particular point in time rather than justice overall. This is thinking about healthcare in the wrong way, it is like trying to understand a 3d scene by looking at a 2d snapshot – you can get an idea of what is happening but certainly not a complete understanding.

So what is the way forward in philosophical thinking about distributive justice in health care? Unfortunately I don’t have much positive to say, it is a matter I think of trying to be sensitive to the complexities of the actuality of health care decision making and muddling through.

Cancer drugs and magic money fountains of youth

26 Mar, 12 | by David Hunter

The McMillian Cancer trust has published a report described on the radio as I drove to Manchester this morning as a damming and shameful report about the NHS and discrimination. The report alleges that more than 14 thousand elderly cancer sufferers are allowed to die in the UK because of age based discrimination.
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