Saturday, April 23, 2016

The Projective Character of Being

In the 2015 NBA draft, when Kristaps Porzingis was selected by the NY Knicks as the fourth overall pick in the first round, he was widely regarded as a “project,” a player whose skills would have to be developed over the course of a few seasons before he would be ready to play at an NBA level (a NY Times headline said, “2015 NBA Draft: Kristaps Porzingis is a Big Project for the Rebuilding Knicks.”1). However, in his first season, Porzingis proved his doubters wrong by showing remarkable skills as a shooter, rebounder, and defender, averaging 14 points, 7 rebounds, 1.9 blocks, and 28 minutes per game and becoming one of the Knicks’ most exciting and beloved players.
     In what sense then is it possible for all of us to rightfully say of ourselves that we are “projects”? If we see ourselves as individuals whose social, professional, or technical skills need to be further developed and refined, as people whose lives are incomplete and unfinished, as human beings whose possibilities and potentialities remain only partially actualized or fulfilled, then we may rightfully describe ourselves as “projects.”
      We may also describe ourselves as projects insofar as we project ourselves into the future and imagine ourselves to be what we have the potential to be and what we might possibly become. Our projectedness may be defined by the extent to which we direct ourselves toward the future and think of the future in our thinking about ourselves. Our projectedness may also be defined by the extent to which we think in terms of what we may, could, or should become.
      We may also be projects insofar as we are unschooled, unrefined and unpolished in our skills and abilities, and insofar as we are undisciplined and unreliable in our behavior. We may also be projects insofar as we are “not ready for prime time” and are unprepared for the challenges that await us.
      We may also see ourselves, or be seen by others, as projects if we have obvious flaws or deficiencies that need to be corrected. We may be seen as projects if we are inattentive to our tasks and undisciplined in fulfilling our duties. We may be seen as projects if we are easily distractible or capable of lapses of judgment, if we are perceived as untrustworthy and undependable, and if we are seen as lacking in steadfastness and commitment.
      We may also be seen as long-term or continuing projects if considerable time and effort will need to be invested in us in order for us to fulfill our duties as fathers, mothers, sons, daughters, teachers, students, friends, colleagues, supervisors, employees, etc., and in order for us to fulfill whatever other duties we may be called upon to acknowledge and comply with. At some point, we may have to decide whether our own investment of time and effort in a given person or project is worthwhile, and whether a given project that seems not to be making progress will ever fulfill its potentialities. If a project ultimately seems to be promising and to be a worthwhile investment, then we may simply have to await its further maturation and development. We may have to be patient, and renew our investment of time and effort, and wait for a successful outcome.
      Martin Heidegger, in Sein und Zeit (Being and Time, 1927), describes the projective character of being-there (Da-sein) by saying:

 “The projective character of understanding constitutes being-in-the-world with regard to the disclosedness of its there as the there of a potentiality of being…And as thrown, Da-sein is thrown into the mode of being of projecting. Projecting has nothing to do with being related to a plan thought out, according to which Da-sein arranges its being, but, as Da-sein, it has already projected itself and is, as long as it is, projecting. As long as it is, Da-sein always has understood itself and will understand itself in terms of its possibilities.”2

Thus, Heidegger says that our being is inseparable from our projecting of ourselves into the future. Our being is disclosed to us as thrown possibility. The “there” of being-there is the “thrownness” of its being, because being-there discovers that it is always being-in-the-world.
      José Ortega y Gasset, in a series of articles entitled “¿Qué es conocimiento?" ("What is Knowledge?", 1931), based on lectures he delivered in 1929-30 at the University of Madrid, describes the projective character of being by saying:

“When I say that “I am a project,” I am referring to the fact that my mind sometimes deliberately sets about to think of the future and to construct, at pleasure, a program to live by. I am not a program I have thought about; if at all, I am the one who is thinking of his future…Thus, I would likewise say that I encounter myself being the project I am before I wonder which project I am. What is more: none of us has ever succeeded in thinking through the project each one of us is. That is why at Delphi the commandment, “Know thyself!” was inscribed as a utopian imperative and, so to speak, as a summit hardly reachable [by us].”3

Thus, Ortega y Gasset says that our becoming our future selves discloses to us the project that our present selves are. We anticipate ourselves constantly in the present, and we project ourselves into the future through our present actions.


FOOTNOTES

1Scott Cacciola, “2015 N.B.A. Draft: Kristaps Porzingis Is a Big Project for the Rebulidng Knicks,” in The New York Times, June 25, 2015.
2Martin Heidegger, Being and Time: A Translation of Sein und Zeit, translated by Joan Stambaugh (Albany: State University of New York Press, 1996), p. 136.
3José Ortega y Gasset, What Is Knowledge?, translated and edited by Jorge García-Gómez (Albany: State University of New York Press, 2002), p. 132.

Friday, April 22, 2016

Maryland's Tuskegee Experiment, 2016

According to the current Maryland Medical Assistance Program guidelines, Medical Assistance (Medicaid) patients with hepatitis C are denied insurance coverage for the treatment of their disease if they are early stage (stage 0 or stage 1). Only patients with stage 2 or higher, in most cases, are approved for treatment. Patients with stage 0 or stage 1 must progress to stage 2 or higher before the Maryland Medical Assistance Program will approve treatment for them.
      The demographics of hepatitis C are such that there are thousands of patients in Maryland, many of them in Baltimore, many of them African-American, who need treatment for hepatitis C. Maryland's denial of insurance coverage to a significant subset of these patients bears some similarities to the infamous Tuskegee Experiment, a research study conducted by the U.S. Public Health Service between 1932-1972, in which African-American men in Macon County, Alabama were denied treatment for syphilis, even after penicillin became available as a cure for the disease.
      There is currently a cure for hepatitis C (ledipasvir/sofosbuvir has a cure rate of greater than 95% in patients infected with genotype 1), but the state of Maryland, because of budgetary considerations, is denying treatment to the subset of patients with early-stage disease, even though their disease is easily curable. Hepatitis C, if untreated, can cause a variety of serious and potentially fatal complications, such as cirrhosis, liver failure, and liver cancer. Thus, treatment for hepatitis C can be lifesaving.
      Basically, physicians in Maryland are being told to say to some of their patients, "We can't treat you for hepatitis C, even though it's a serious illness that could cause you to have long-term health problems, including a risk of severe liver damage and liver cancer. You have to get sicker before we can treat you." This is not the way that physicians treat patients with other chronic, significant health problems.
      Of course, the denial of treatment to patients with hepatitis C is not just a problem in Maryland; in California, Washington, and Florida the denial of treatment to patients with hepatitis C by insurance companies has already become a subject of litigation. According to a study by Edlin, et al. (Hepatology, Aug. 25, 2015), there are at least 3.5 million people in the United States who are currently infected with hepatitis C. Physicians who treat hepatitis C often have to file appeals on behalf of their patients when approval of treatment is denied by public or private insurers.
      According to the 2016 guidelines provided by the American Association for the Study of Liver Disease (AASLD) and the Infectious Diseases Society of America (IDSA), "Treatment is recommended for all patients with chronic HCV (hepatitis C virus) infection, except those with short life expectancies that cannot be remediated by treating HCV, by transplantation, or by other directed therapy," and "clinicians should treat HCV-infected patients with antiviral therapy with the goal of achieving an SVR (sustained virologic response), preferably early in the course of chronic HCV infection before the development of severe liver disease and other complications" (www.hcvguidelines.org).
      Of course, there are a number of factors that have to be considered regarding the cost of treatment and the likelihood of treatment benefit. Which patients are likely to benefit the most from treatment? Certainly, the stage and activity of the disease in patients must be considered in deciding who will benefit the most. But let's look at the patient population that's currently being denied access to treatment. The impact of Maryland's budgetary constraints falls most heavily on the poor, on those who are most economically disadvantaged.
      Moreover, the denial of insurance coverage for treatment of hepatitis C by public and private insurers is presently not justified by medical or scientific opinion concerning treatment of the disease; it is based solely on cost considerations. Insurers cannot therefore rightfully claim that denial of treatment is based on considerations of medical necessity. According to the AASLD/ISDA guidelines, hepatitis C treatment is recommended for nearly all patients with the disease.
      This issue needs to be discussed further in the public sphere, and there needs to be greater public awareness that "health care rationing" has become a part of our health care system. There needs to be wider public discussion of the ethics and management of health care rationing, and there needs to be wider discussion of the measures that can be taken to utilize our health care resources more efficiently and equitably, as well as wider discussion of the steps that can be taken to control costs, increase affordability, remove barriers to access, encourage innovation, and achieve other aspects of health care system reform.

ADDENDUM:

On Friday, May 27, 2016, U.S. District Court Judge John C. Coughenour ruled that Washington State's Medicaid program must cover treatment for all patients with hepatitis C, regardless of the stage of their disease. In his ruling, Judge Coughenour said that untreated patients are likely to suffer irreparable harm, and that under Title XIX of the Social Security Act (which establishes federal guidelines for state Medicaid programs), patients cannot be denied access to medically necessary care.

Saturday, April 2, 2016

The Moral High Ground

There were a variety of celebrity feuds in 2015 (Donald Trump vs. Megyn Kelly, Floyd Mayweather vs. Ronda Rousey, Drake vs. Meek Mill, Taylor Swift vs. Katy Perry) in which one or another of the disputants was alleged to have sought to end the feud by “taking the high road,” that is to say, by refusing to respond to some disparaging remark made about him or her and thereby at least temporarily allowing the dispute to be put to rest.
      Similarly, there were several occasions during the early months of the U.S. presidential campaign in 2015-2016 when Democratic and Republican candidates "took the high road" by refraining from personal attacks against one another. For example, Sen. Bernie Sanders, during a debate with Sec. Hillary Clinton on Oct. 13, 2015, refused to attack her for her use of a private email server to access classified email communications while she was U.S. Secretary of State from 2009-2013. Sanders said, "Enough of the emails. Let's talk about the real issues facing America." Sen. Ted Cruz, on Feb 22, 2016, said that he was “taking the high road” by firing his communications director for having posted a video on Facebook that falsely accused Sen. Marco Rubio of having insulted the Bible. Gov. John Kasich, on Mar. 14, 2016, said, "I will not take the low road to the highest office in the land." Unfortunately, there were also many occasions during the campaign when the candidates did indeed engage in scathing personal attacks against one another.
      What then does it mean to “take the high road” or to “claim the moral high ground”? A variety of explanations may be proposed: taking the high road means being fair, just, kind, and forgiving, and being guided by one’s better and more virtuous impulses. It means treating others as one would like oneself to be treated, rather than as one has been treated by others (although if one has been treated kindly and generously, then one may have a duty to reciprocate).
      Taking the high road also means being mindful, considerate, and understanding of others’ thoughts and feelings. It means turning the other cheek, being tolerant of others’ faults and transgressions, and showing forbearance and self-restraint.
      To take the high road is also to refrain from responding to spiteful and hateful personal attacks against one’s motives, conduct, character, or reputation by launching the same kind of spiteful and hateful personal attacks against those who have initiated them (“taking the low road”). It is also to refrain from pettiness, vindictiveness, revenge, dirty tricks, ad hominem attacks, and attempts to suppress free speech. It is not to descend to the level of those who will use any means at their disposal, no matter how callous, cruel, or heartless, to promote their own personal advantage.
      To claim the moral high ground is not to indulge in “tit for tat.” It is to refrain from always having to have the last word. It is to understand that one may not always be able to change the attitudes and opinions of those with whom one disagrees. It is to accept the fact that there may always be differences of opinion between individuals, and that some individuals’ opinions may be difficult to change.
      To claim the moral high ground is also to be scrupulous about the means that one chooses to advance one’s own ends. It is to keep in mind the needs of those who are disadvantaged and suffering, and to defend the rights of those who have been abused, victimized, stigmatized, discriminated against, or oppressed. It is not to actively or passively condone moral injustice or social oppression. It is to appeal to people’s unselfish and altruistic impulses, and not to surrender to the politics of fear. It is also to promote political, economic, and cultural pluralism, and to encourage peaceful means of conflict resolution.
      To take the high road is also to do whatever is morally right, regardless of any personal inconvenience or disadvantage to oneself. It is not to merely do whatever is expedient in order to solve a problem or settle a conflict. It is also not to engage in devious practices or underhanded quid pro quo transactions.
      Sometimes when people are angry, it may be helpful to let them vent their feelings in order to defuse their anger. “Taking the high road” may mean simply listening to them and not trying to make them understand one’s own feelings of being unfairly subjected to their complaints and criticisms.
      Robert H. Frank (1996) asks the question: at what personal cost (or at what level of personal disadvantage) will we still be willing to take the moral high ground? What kinds of sacrifices, if necessary, will we be prepared to make? Frank argues that various kinds of social and economic choices may be significantly influenced by unselfish motives. For example, the career choices of individuals may be influenced not only by financial incentives, but also by social incentives provided by opportunities to help others and contribute to society. The ability of a corporation to attract new employees may depend not only on its ability to offer attractive financial compensation, but also on its ability to demonstrate social responsibility. Employees may require much higher salaries before being willing to switch to less socially responsible employers.1
      While taking the high road may be praiseworthy insofar as it is motivated by the desire to act virtuously, it may also be unpraiseworthy insofar as it is motivated by self-righteousness, arrogance, and condescension. Telling others that one is taking the high road may be self-serving. It may be a means of praising and congratulating oneself about one’s own level of self-restraint, even when one has engaged in needless arguments and petty disputes. It may also be a means of allowing oneself to say that one will not descend to a certain level of debate, thus expressing scorn or disdain for whomever is deemed to have engaged in that level of debate. Telling others that one is taking the high road may also be a method of saving face, and may represent a fallacy of relevance whereby the superiority of one’s own motives or intentions is asserted in order to establish the truth and validity of one’s beliefs or opinions.
      If a particular set of moral rules or principles is said to characterize a moral high ground, then what makes that ground higher than other grounds?  Is it because those moral rules or principles are somehow higher, more far-reaching, and of greater priority than others, or because they reflect a higher set of moral values?
      A ground for something may also be a reason, explanation, or justification for that thing. The sufficiency of a ground may thus be its reason-giving ability, its foundational or justificatory capacity, and its explanatory power. The more sufficient the ground, the greater may be its justificatory capacity and explanatory power.
      Paul Bloomfield (2003) explains that the concept of a moral high ground may generate a theoretical topology of normative ethical positions whereby some moral positions are higher or lower than others in terms of their normative consequence or theoretical validity. The notion of a level playing field of normative positions (or the notion that no normative position is higher than others in terms of its consequence or validity) may lead to a form of moral relativism (or the view that all normative positions are equally valid, and that their normative consequence or theoretical validity depends merely on the subjective viewpoint of the observer).2
      Taking the high road may require one to act from a position of strength rather than weakness, since one may not be able to take the high road if one is desperate to make use of any means at one’s disposal in order to gain advantage in a dispute or controversy. At the same time, the taking of the high road or the claiming of the moral high ground may itself bestow strength upon the taker or claimant. The high road or moral high ground is to some degree a path to, or a position of, moral power and authority.


FOOTNOTES

1Robert H. Frank, “What Price the Moral High Ground?” in Southern Economic Journal, Vol. 63, No. 1 (July, 1996), pp. 1-17.
2Paul Bloomfield, “Is There Moral High Ground?” in The Southern Journal of Philosophy, Vol. XLI (2003), pp. 511-512.