The examples and perspective in this article deal primarily with the United States and do not represent a worldwide view of the subject. Please improve this article and discuss the issue on the talk page.

The philosophy of healthcare is the study of the ethics, processes, and people which constitute the maintenance of health for human beings. (Although veterinary concerns are worthy to note, the body of thought regarding their methodologies and practices is not dealt with in this article.) For the most part, however, the philosophy of healthcare is best approached as an indelible component of human social structures. That is, the societal institution of healthcare can be seen as a necessary phenomenon of human civilization whereby an individual continually seeks to improve, mend, and alter the overall nature and quality of his or her life.

The philosophy of healthcare is primarily concerned with the following elemental questions:

• Who requires and/or deserves healthcare? Is healthcare a fundamental right of all people?

• What should be the basis for calculating the cost of treatments, hospital stays, drugs, etc.?

• How can healthcare best be administered to the greatest number of people?

• What are the necessary parameters for clinical trials and quality assurance?

• Who, if anybody, can decide when a patient is in need of "comfort measures" (euthanasia)?

Ultimately, the purpose, objective, and meaning of healthcare philosophy is to consolidate the abundance of information regarding the ever-changing fields of biotechnology, medicine, and nursing. And seeing that healthcare typically ranks as one of the largest spending areas of governmental budgets, it becomes important to gain a greater understanding of healthcare as not only a social institution, but also as a political one. In addition, healthcare philosophy attempts to highlight the primary movers of healthcare systems; be it nurses, doctors, hospital administrators, health insurance companies (HMOs and PPOs), the government (Medicare and Medicaid), and lastly, the patients themselves.

Contents 1 Ethics in healthcare 1.1 Bioethics 1.2 Medical ethics 1.3 Nursing ethics 1.4 Business ethics 2 Politics in healthcare 2.1 Patients' Bill of Rights 3 Research and scholarship 3.1 Clinical trials 3.2 Quality assurance 4 Birth and death 4.1 Reproductive rights 4.2 Birth and living 4.3 Death and dying 5 Role development 6 See also 7 References 8 External links

[edit] Ethics in healthcare

The ethical and moral premises of healthcare are convoluted and numerous. In order to consolidate such an enormous field of ethical thought, it becomes necessary to focus on what makes healthcare ethics truly different from other forms of morality. And on the whole, it can be said that healthcare itself is a "special" institution within society.^[1] With that said, healthcare ought to "be treated differently from other social goods" in a society.^[2] It is an institution of which we are all a part whether we like it or not. At some point in a every person's life, a decision has to be made regarding her healthcare. Can she afford it? Does she deserve it? Does she need it? Where should she go to get it? Does she even want it? And it is this last question which poses the biggest dilemma facing a person. After weighing all of the costs and benefits of her healthcare situation, the person has to decide if it is even worth it. It is not simply economic issues that are at stake in this conundrum. In fact, a person must decide whether or not her life is at its end or if it is worth salvaging. Of course, in instances where the patient herself is unable to decide due to medical complications, like a coma, then the decision must come from elsewhere. And defining that "elsewhere" has proven to be a very difficult endeavor in healthcare philosophy.

[edit] Bioethics

According to French philosopher Luc Ferry, the field of bioethics represents a "sacralization of the human body," whereby the body effectively "becomes a temple."^[3] This viewpoint of bioethics is rather interesting for it makes an intrinsic connection between the integrity of the human body and spirituality. Even so, this perspective on bioethics contains a hint of what Ferry refers to as "transcendental humanism," in which reason has succeeded in subverting religion insofar as traditional morality is concerned.^[4] In a classically French existentialist manner, Ferry proceeds to assert:

Never before, without a doubt, has the progress of science and technology given rise to questions with such broad moral and, let us dare to use the word, metaphysical implications. It is as though the sense of the sacred remains, in spite of the "death of God," but without our being given the spirituality or wisdom that should correspond to it.^[5]

This assertion can essentially be seen as an effective summary of the philosophical issues raised in bioethics.

[edit] Medical ethics

Whereas bioethics tends to deal with more broadly-based issues like the consecrated nature of the human body and the roles of science and technology in healthcare, medical ethics is specifically focused on applying ethical principals to the field of medicine. It is a large and relatively new area of study in ethics. And one of the major premises of medical ethics surrounds "the development of valuational measures of outcomes of health care treatments and programs; these outcome measures are designed to guide health policy and so must be able to be able to be applied to substantial numbers of people, including across or even between whole societies."^[6] Terms like beneficence and non-maleficence are vital to the overall understanding of medical ethics. Therefore, it becomes important to acquire a basic grasp of the varying dynamics that go into a doctor-patient relationship.

[edit] Nursing ethics

Like medical ethics, nursing ethics is very narrow in its focus, especially when compared to the expansive field of bioethics. For the most part, "nursing ethics can be defined as having a two-pronged meaning," whereby it is "the examination of all kinds of ethical and bioethical issues from the perspective of nursing theory and practice."^[7]This definition, although quite vague, centers on the practical and theoretical approaches to nursing. The American Nurses Association (ANA) endorses an ethical code that emphasizes "values" and "evaluative judgments" in all areas of the nursing profession.^[8] And since moral issues are extremely prevalent throughout nursing, it is important to be able to recognize and critically respond to situations that warrant and/or necessitate an ethical decision.

[edit] Business ethics

Balancing the cost of care with the quality of care is a major issue in healthcare philosophy. In Canada and some parts of Europe, democratic governments play a major role in determining how much public money from taxation should be directed towards the healthcare process. In the United States and other parts of Europe, private health insurance corporations as well as government agencies are the agents in this precarious life-and-death balancing act. According to medical ethicist Leonard J. Weber, "Good-quality healthcare means cost-effective healthcare," but "more expensive healthcare does not mean higher-quality healthcare" and "certain minimum standards of quality must be met for all patients" regardless of health insurance status.^[9] This statement undoubtedly reflects the varying thought processes going into the bigger picture of a healthcare cost-benefit analysis. In order to streamline this tedious process, health maintenance organizations (HMOs) like BlueCross BlueShield employ large numbers of actuaries (colloquially known as "insurance adjusters") to ascertain the appropriate balance between cost, quality, and necessity of care for a patient.^{[citation needed]} Another general rule in the health insurance industry is as follows:

The least costly treatment should be provided unless there is substantial evidence that a more costly intervention is likely to yield a superior outcome.^[10]

This generalized rule for healthcare institutions "is perhaps one of the best expressions of the practical meaning of stewardship of resources," especially since "the burden of proof is on justifying the more expensive intervention, not the less expensive one, when different acceptable treatment options exist."^[11]

[edit] Politics in healthcare

Much has been said with regard to the political philosophy of healthcare. The debate surrounding universal health care and private health care is particularly potent in the United States. The 1960s however saw a plethora of concrete moves by the federal government to consolidate and modernize the U.S. healthcare system. With Lyndon Johnson's Great Society initiative, the U.S. established public health insurance for both senior citizens and the underprivileged. Known as Medicare and Medicaid, these two healthcare programs granted certain groups of Americans access to adequate healthcare services. Although these healthcare programs were a giant step in the direction of socialized medicine, many people think that the U.S. needs to do more for its citizenry with respect to healthcare coverage.^[12] Opponents of universal health care see it as a dumbing down of the healthcare quality that already exists in the United States.^[13]

[edit] Patients' Bill of Rights

In 2001, the federal government of the United States undertook an initiative to provide patients with an explicit list of rights concerning their healthcare. This initiative was essentially taking some of ideas found in the Consumers' Bill of Rights and applying it to the field of healthcare. It was undertaken in an effort to ensure the quality of care of all patients by preserving the integrity of the processes that occur in the healthcare industry.^[14] Standardizing the nature of healthcare institutions in this manner proved rather provocative. In fact, many interest groups, including the American Medical Association (AMA) and the pharmaceutical industry came out vehemently against the congressional bill. Basically, providing emergency medical care to anyone, regardless of health insurance status, as well as the right of a patient to hold their health plan accountable for any and all harm done proved to be the biggest stumbling blocks for this bill.^[15] As a result of this intense opposition, the initiative eventually failed to pass Congress in 2002.

[edit] Research and scholarship

Considering the rapid pace at which the fields of medicine and health science are developing, it becomes important to investigate the most proper and/or efficient methodologies for conducting research. On the whole, "the primary concern of the researcher must always be the phenomenon, from which th research question is derived, and only subsequent to this can decisions be made as to the most appropriate research methodology, design, and methods to fulfill the purposes of the research."^[16] This statement on research methodology places the researcher at the forefront of his findings. That is, the researcher becomes the person who makes or breaks his or her scientific inquiries rather than the research itself. Even so, "interpretive research and scholarship are creative processes, and methods and methodology are not always singular, a priori, fixed and unchanging."^[17] Therefore, viewpoints on scientific inquiries into healthcare matters "will continue to grow and develop with the creativity and insight of interpretive researchers, as they consider emerging ways of investigating the complex social world."^[18]

[edit] Clinical trials

Clinical trials are a means through which the healthcare industry tests a new drug, treatment, or medical device. The traditional methodology behind clinical trials consists of various phases in which the emerging product undergoes a series of intense tests, most of which tend to occur on interested and/or compliant patients. The U.S. government has an established network for tackling the emergence of new products in the healthcare industry. The Food and Drug Administration (FDA) typically conducts appropriate trials on new drugs coming from pharmaceutical companies.^[19] Along with the FDA, the National Institutes of Health sets the guidelines for all kinds of clinical trials relating to infectious diseases. For cancer, the National Cancer Institute (NCI) sponsors a series or cooperative groups like CALGB and COG in order to standardize protocols for cancer treatment.^[20]

[edit] Quality assurance

The primary purpose of quality assurance (QA) in healthcare is to ensure that the quality of patient care is in accordance with established guidelines. The government usually plays a significant role in providing structured guidance for treating a particular disease or ailment. However, protocols for treatment can also be worked out at individual healthcare institutions like hospitals and HMOs. In some cases, quality assurance is seen as a superfluous endeavor, as many healthcare-based QA organizations, like QARC, are publicly funded at the hands of taxpayers.^[21] However, many people would agree that healthcare quality assurance, particularly in the areas cancer treatment and disease control are necessary components to the vitality of any legitimate healthcare system. With respect to quality assurance in cancer treatment scenarios, the Quality Assurance Review Center (QARC) is just one example of a QA facility that seeks "to improve the standards of care" for patients "by improving the quality of clinical trials medicine."^[21]

[edit] Birth and death

[edit] Reproductive rights

Everybody who wishes to have a child wants it to be perfect (at least at birth). Nobody wants and/or wishes for their child to be born with Down Syndrome or Cerebral Palsy. In fact, obstetricians have the most medical malpractice lawsuits filed against them. As a result, they have to pay the highest premiums for malpractice insurance. These high costs inevitably become a hindrance not only to the doctors, but also to the healthcare industry as a whole. And although patients and their families have the right to appeal and confront a physician regarding the quality of treatment received, there must be a limit as to how far they can go. Frivolous lawsuits are clearly becoming a major problem for healthcare providers.

The ecophilosophy of Garrett Hardin constitutes one perspective from which to view the reproductive rights of human beings. For the most part, Hardin argues that it is immoral to have large families, especially since it does a disservice to society in the sense that there is only a finite number of resources in the world. In an essay entitled The Tragedy of the Commons, Hardin states,

To couple the concept of freedom to breed with the belief that everyone born has an equal right to the commons is to lock the world into a tragic course of action.^[22]

This statement essentially summarizes Hardin's major point concerning the negligible right of all human beings to procreate. Moreover, Hardin is a vocal critic of the United Nations' Universal Declaration of Human Rights (UDHR), which states that "any choice and decision with regard to the size of the family must irrevocably rest with the family itself, and cannot be made by anyone else."^[23]

With respect to healthcare philosophy, Hardin's ecophilosophical views may seem like a stretch. Nevertheless, they are important to keep in mind, especially when considering the call for healthcare as a universal birth right of all people. The increasing strains placed on healthcare systems are primarily the result of a growing human population. One way of mitigating healthcare costs is to moderate population growth. The fewer people there are to take care of, the less expensive healthcare will become. And to apply this logic to what medical ethicist Leonard J. Weber previously suggested, less expensive healthcare does not necessarily mean poor-quality healthcare.^[24]

[edit] Birth and living

The concept of being "well-born" is not new. On the whole, it takes on a fairly racist undertone. The Nazis practiced eugenics in order to cleanse the gene pool of what were perceived to be unwanted or harmful elements. This "race hygiene movement in Germany evolved from a theory of Social Darwinism, which had become popular throughout Europe" and the United States during the 1930s.^[25] A German phrase that embodies the whole nature of this practice is lebensunwertes Leben or "life unworthy of life."^[26]

In connection with healthcare philosophy, the theory of natural rights becomes a rather pertinent subject. After birth, man is effectively endowed with a series of natural rights that cannot be banished under any circumstances. One major proponent of natural rights theory was seventeenth century English political philosopher John Locke. With regard to the natural rights of man, Locke states,

If God's purpose for me on earth is my survival and that of my species, and the means to that survival are my life, health, liberty and property — then clearly I don't want anyone to violate my rights to these things.^[27]

Although tarnished by the partiality of religion, Locke's statement can essentially be viewed as an affirmation of the right to preserve one's life at all costs. This point is precisely where healthcare as a human right comes into the picture.

The process of preserving and maintaining one's health throughout life is a matter of grave concern. Once alive, how should people exercise their natural right to preserve their life through good health? At some point in every person's life, his or her health is going to decline regardless of all measures taken to prevent such a collapse. Coping with this inevitable decline can prove quite problematic for some people. For Enlightenment philosopher René Descartes, the depressing and gerontological implications of aging pushed him to believe in the prospects of immortality through a wholesome faith in the possibilities of reason.^[28]

[edit] Death and dying

One of the most basic human rights is the right to live, and thus, preserve one's life. But what about the right to die, and thus, end one's life? Needless to say, this is a very controversial topic. Often, religious values of varying traditions tend to seep into the picture in one fashion or another. Terms like "mercy killing" and "assisted suicide" are frequently used to describe this process. Proponents of euthanasia claim that it is particularly necessary for patients suffering from a terminal illness.^[29] However, opponents of a self-chosen death purport that it is not only immoral, but wholly against the pillars of reason.

In a certain philosophical context, death can be seen as the ultimate existential moment in one's life. Death is the deepest cause of a primordial anxiety (Die Anfechtung) in a person's life. And it is in this emotional state of anxiety that "the nothing" is revealed to the person. According to twentieth century German existentialist philosopher Martin Heidegger,

The nothing is the complete negation of the totality of beings.^[30]

And thus, for Heidegger, humans finds themsleves in a very precarious and fragile situation (constantly hanging over the abyss) in this world. This concept can be simplified to the point where at bottom, all that a persson has in this world is his or her Being. And no matter how individuals proceed in life, their existence will always be marked by finitude and solitude. The prospect or self-realization that one's life is about to end is quite frightening to say the least. But why is this the case? When considering near-death experiences, humans feels this primordial anxiety overcome them. It robs them of speech and thought, but not feeling. Therefore, it is important for healthcare providers to recognize the onset of this entrenched despair in patients who are nearing their respective deaths.

Another philosophical inquiry into death centers on the heavy reliance on science and technology in the healthcare profession. This reliance is especially evident in Westernized medicine, as it is difficult to make apt connections to primitive means of healthcare in the developing world. Even so, Heidegger makes a rather fascinating allusion to this reliance in what he calls the allure or "character of exactness."^[31] In effect, man is inherently attached to "exactness" because it gives him a sense of purpose or reason in a world that is largely defined by what appears to be chaos and irrationality. And as the moment of death is approaching, a moment marked by utter confusion and fear, he tries to locate a sense of meaning and purpose behind it all.

[edit] Role development

The manner in which nurses, physicians, patients, and administrators interact is crucial for the overall efficacy of a healthcare system. From the viewpoint of the patients, healthcare providers can be seen as being in a privileged position, whereby they have the power to alter the patients' quality of life. And yet, there are strict divisions among healthcare providers that can sometimes lead to an overall decline in the quality of patient care. When nurses and physicians are not on the same page with respect to a particular patient, a compromising situation may arise. Effects stemming from a "gender gap" between nurses and doctors are detrimental to the professional environment of a hospital workspace.^[32]

Aside from role development, another area in healthcare philosophy that necessitates discussion is palliative care. Otherwise known as hospice care, this area of healthcare philosophy is becoming increasingly important as more patients are preferring to receive healthcare services in their homes. Even though the terms "palliative" and "hospice" are typically used in an interchangeable fashion, they are actually quite different. And the major difference resides in the fact that hospice care is a benefit associated with Medicare while palliative care is not.^[33] As a patient nears the end of his life, it is more comforting to be in a private home-like setting instead of a hospital. Palliative care has generally been reserved for those who have a terminal illness. However, it is now being applied to patients in all kinds of medical situations, including chronic fatigue and other bothersome symptoms.^[34]

[edit] See also

• Ethical problems using children in clinical trials

[edit] References

[edit] External links

• Summary of the McCain-Edwards-Kennedy Patients' Bill of Rights
• Understanding Clinical Trials
• Mission Statement of the National Cancer Institute (NCI)
• Guidance for Industry, Investigators, and Reviewers in Exploratory Drug Studies (FDA January 2006)
• Quality Assurance Review Center
• "Palliative Care across the Continuum" (Center to Advance Palliative Care)
• "Hospice Care Center" Centers for Medicare and Medicaid Services (CMS)
• "Universal Declaration of Human Rights (UDHR)" (United Nations)
• Medicare (The Official U.S. Government Site for People with Medicare)
• Historical Background and Development of Social Security; includes information about Medicare

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