Friday, April 22, 2016

Maryland's Tuskegee Experiment, 2016

According to the 2016 Maryland Medical Assistance Program guidelines,* Medical Assistance (Medicaid) patients with hepatitis C were denied insurance coverage for the treatment of their disease if they were early stage (stage 0 or stage 1). Only patients with stage 2 or higher, in most cases, were approved for treatment. Patients with stage 0 or stage 1 had to progress to stage 2 or higher before the Maryland Medical Assistance Program would approve treatment.
      The demographics of hepatitis C were such that there were thousands of patients in Maryland, many of them in Baltimore, many of them African-American, who needed treatment for hepatitis C. Maryland's denial of insurance coverage to a significant subset of these patients bore 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.
      In 2016 there was an available cure for hepatitis C (ledipasvir/sofosbuvir had a cure rate of greater than 95% in patients infected with genotype 1), but the state of Maryland, because of budgetary considerations, denied treatment to the subset of patients with early-stage disease, even though their disease was 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 were 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 was not just a problem in Maryland; in California, Washington, and Florida the denial of treatment to patients with hepatitis C by insurance companies had already become a subject of litigation. According to a study by Edlin, et al. (Hepatology, Aug. 25, 2015), in 2016 there were at least 3.5 million people in the United States who were infected with hepatitis C. Physicians who treated hepatitis C often had to file appeals on behalf of their patients when approval of treatment was 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 were, and still 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 looking at the patient population most likely to be denied access to treatment, the impact of Maryland's budgetary constraints fell most heavily on the poor, on those who were most economically disadvantaged.
      Moreover, the denial of insurance coverage for treatment of hepatitis C by public and private insurers wasn't justified by medical or scientific opinion concerning treatment of the disease; it was based solely on cost considerations. Insurers could not therefore rightfully claim that denial of treatment was based on considerations of medical necessity. According to AASLD/ISDA guidelines, hepatitis C treatment is recommended for nearly all patients with the disease.
      This issue still 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.

*Maryland Medicaid finally lifted its coverage restrictions in 2020 to allow treatment of hepatitis C for all patients, regardless of the stage of their disease.

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.




Saturday, March 19, 2016

WIlhelm Vossenkuhl's The Possibility of the Good

Wilhelm Vossenkuhl is a German philosopher who was born Dec. 11, 1945 in Engen, Germany. He is the author of many books, essays, and articles, and has taught at many universities, including Bayreuth (1986-1993), Halle-Wittenburg (1990-91), Freiburg, Krakow, Lodz, and Ludwig Maximilian University of Munich (1993-2011). He is currently professor emeritus of philosophy at LMU Munich. 
      His writings have included Ludwig Wittgenstein (1995), Philosophie für die Westentasche (Philosophy for the Vest Pocket, 2004), Die Möglichkeit des Guten (The Possibility of the Good, 2006), Solipsismus und Sprachkritik (Solipsism and Language Criticism, 2009), Philosophie: Basics (2011), and Die Grossen Denker (The Great Thinkers, with Harald Lesch, 2012). 
      His research has centered on epistemology, ethics, the history of philosophy, action theory, and the philosophy of language, and he has explored the work of such philosophers as William of Ockham, Immanuel Kant, Henry Sidgwick, Rudolf Carnap, and Ludwig Wittgenstein. 
      He appeared with Harald Lesch, the German physicist, astronomer, and philosopher, on the television series, Lesch & Co. (2001-2006), and Denker des Abendlandes (Thinkers of the Western World, 2008-2014). Lesch is currently professor of theoretical astrophysics at LMU Munich and professor of natural philosophy at the Munich School of Philosophy.
      Honors that Vossenkuhl has received include the International Prize for Philosophy from the Margrit Egnér Foundation (1998), honorary membership in the Sokratischen Gesellschaft (Socratic Society) since 2009, and fellowship at the Centre for the Study of Democracy (Queen’s University, Kingston, Ontario, 2004-2011).
      In 2010, Asteroid no. 210174 was named “Vossenkuhl” by the International Astronomical Union (IAU) in Paris and the Minor Planet Center at Harvard University, at the suggestion of Rolf Apitzsch (Wildberg Observatory, Wildberg, Germany), who discovered the asteroid.1
      As of 2016, Vossenkuhl’s major writings have not yet been translated into English. Philosophie für die Westentasche has been translated into Dutch, Italian, and Korean, and Die Möglichkeit des Guten has been translated into Polish. Lexikon der Ethik (2008, co-edited by Otfried Höffe, Maximilian Forschner, Christoph Horn, and Wilhelm Vossenkuhl) has been translated into Italian, Spanish, and Chinese.2
      In Die Möglichkeit des Guten: Ethik im 21. Jahrhundert (The Possibility of the Good: Ethics in the 21st Century), he describes ethics as a practical science that seeks to answer two basic questions: how “the good” is possible, and how the good, in the form of “the good life,” can be actualized. He says that these two basic questions are inseparable, and that the clarification of the possibility of the good is actually the first step toward the actualization of the good life.3
      The clarification of the possibility of the good involves both a theoretical and a practical commitment. The theoretical commitment to internal and external consistency in our ethical judgments must underlie a practical commitment to coherence. We cannot find the best solutions to ethical problems (those solutions that enable the best possible life, under the given conditions, to be actualized for all human beings) unless our ethical judgments are coherent. Such judgments should enable the actualization (or contribute to the actualization) of the best possible life for all human beings, even when moral, legal, or political conflicts between different individuals or groups cannot be resolved. Without the theoretical commitment to consistency and the practical commitment to coherence, our ethical judgments can make no claim to objectivity.4
      Vossenkuhl explains that in every judgment that something is good or bad, we employ a basic standard of what is good or bad. This standard may be moral, ethical, aesthetic, technical, or functional in nature. But within certain limits, the good or bad may change, and thus within certain limits, our standards of what is good or bad must also change.
      The pivotal point of any ethics, according to Vossenkuhl, is the issue of human freedom. Ethics not only presupposes human freedom, it also offers the possibility of promoting and ensuring it. The possibilities of the good increase or decrease with the possibilities of human freedom.5
      Two problems for ethics arise from (1) the fact that there may be a scarcity of goods to be allocated to different individuals or groups, and (2) the fact that it may be difficult to determine how unquantifiable normative claims to goods are to be matched to quantifiable shares of distributable goods. These two problems are the source of what Vossenkuhl calls “the basic methodological problem of ethics,” i.e. the problem of how manifold and diverse goods are to be integrated into a whole, whereby a good life becomes possible for all members of society. He proposes a “maxim method” as the solution of this problem, and he explains that this method provides a means of answering both the question of how the good is possible and the question of how the good, in the form of the good life, can be actualized.
      In considering the relation between ethics and morality, Vossenkuhl says that ethics presupposes morality, and that ethical judgments are always in some way connected to moral presuppositions. Ethics therefore has only a limited independence from morality, and must rely on basic moral norms in order to justify its judgments. Such norms include “moral facts” (sittliche Tatsachen), e.g. the fact that killing human beings is wrong, and the fact that human dignity should be respected. These facts are basic and foundational to ethics, and they do not require further explanation.
      Ethics, on the other hand, seeks to explain why actions are right or wrong, good or bad, and thus it attempts to achieve objective validity for its judgments. Criteria for the objective validity of ethical judgments include truth, understandability, verifiability, relevance, and revisability in light of new facts or knowledge. These five criteria of objectivity are not proposed as absolute or final, but they indicate how ethical validity (ethische Geltung) may be distinguished from moral justification (sittliche Rechtfertigung).
      At the same time, the scientific authority of ethics presupposes the natural authority of morality. Ethics, on the one hand, can have scientific authority only if its foundations are independent of morality, but on the other hand, it would have no scientific authority if it were not rooted in morality.6 Ethics can therefore criticize morality only by deriving its truth claims from morality. This kind of critique is possible only if moral facts can change or be replaced by new moral facts.
      Vossenkuhl explains that conventional morality is usually recognized and accepted as long as it fulfills its customary functions and is supported by regular social practices. It becomes problematic only when it gives good reasons to mistrust regular social practices, and when it puts its own validity into question on ethical grounds.7
      Kant claimed that subjective principles of volition can become objective principles of reason if they comply with the "categorical imperative," which is to act only in such a way that the principle according to which an action is performed can be taken as a universal law of morality. Universal moral commands, such as “keep your promises,” “tell the truth,” “have compassion for others,” and “help the needy as much as you can” correspond to what Kant would describe as objectively valid principles of morality. Vossenkuhl, however, questions whether universality is a meaningful methodological requirement in ethics, and he argues for a situational ethics whose requirements are objectively founded for determinate problems under determinate conditions. He says that every ethics is in some way situational, because it contains elements that characterize the particular individual and collective context of action.8
      Vossenkuhl also describes “ethical normality” (ethishe Normalitätas a conflict-free condition in which there is, for a given moral problem, only one rule that must be followed in order to solve it. Other criteria for ethical normality include: the rule to be followed in a situation must be morally valid, and there are no other rules or obligations that conflict with the rule. If the criteria for ethical normality are not all fulfilled, then there are at least three kinds of problems that may occur: (1) there may be moral conflict when more than one rule or obligation holds in a situation and only one can be fulfilled, (2) there may be moral disagreement over the interpretation of moral facts or the application of ethical principles to particular situations, and (3) there may be "normative overloading"(normative Überforderung) if multiple moral duties or norms cannot all be complied with simultaneously. In the case of (1), two kinds of moral conflicts may occur: those that can be resolved, and those that cannot (moral dilemmas).9
      The limits of ethical normality, according to Vossenkuhl, are not the same as the limits of ethics. If there is no single rule that can be used to resolve a moral conflict, then there are still right and wrong responses to that conflict.10 Moreover, the resolution of moral conflict does not necessarily mean the restoration of ethical normality. In cases of normative overloading, for example, we may be limited to achieving some degree of normative unloading. Such cases of unfulfilled moral duties or obligations cannot simply be resolved like pain is resolved after ingestion of a painkiller. We cannot merely address the symptoms of moral conflict or normative overloading; we must also address the causes of those symptoms.11
      The goal of ethics is the clarification of the question of how the good, in the form of the good life, is possible.12 Among the presuppositions under which the goal of ethics is achievable are that human beings are capable of acting freely, and that they are capable of accepting moral responsibility for their actions. These presuppositions, however, are not purely moral in character, insofar as the nature of human freedom may be partly determined by political, legal, economic, and social conditions.13
      Vossenkuhl says that ethics has presuppositions in a wider, and in a narrower sense. Presuppositions in a wider sense include the importance of respect for human life, the importance of respect for human rights, and the importance of respect for human dignity, and these presuppositions belong to morality. Presuppositions in a narrower sense include the existence of legal jurisprudence, legal protection of civil rights, and legal guarantees of basic human freedoms, and these presuppositions denote the conditions without which ethics could not claim to be a practical science and thus argue independently of morality.
      If the clarification of how the good life is possible is the goal of ethics, and the good life is not of a purely moral nature, then the question of how the good life is possible cannot be answered merely by producing a list of virtues that must be fulfilled or duties that must be complied with.14 It’s always possible for individual actions to be morally good even though the person who performs them has not always acted morally and does not live in a society that makes the good life possible for all. The morally good is a necessary but not sufficient condition for the good life of an individual person or whole society.15
      Morally good actions form the “cement” of the individual and collective good life, and they hold together other elements that are necessary for such a life. Morally bad actions do the opposite; they disrupt the good life.16
      We assume that the good life is possible if a variety of conditions are met, such as when human rights are respected, when no one lives in poverty, when no one is discriminated against, when everyone has equal opportunity for employment, when everyone has access to health care, when everyone can live in peace and security, and when everyone fulfills their duties to one another. Since it seems unlikely that all these ideal conditions will ever simultaneously be fulfilled, we learn to understand the good life as basically incomplete. The good life as a whole is never actually achieved beyond the stage of the possible; its modality is that of a possible actuality.17
      The basic methodological problem of ethics arises from the fact that the goods we need in order to live a good life are often scarce, and from the fact that these goods frequently have an unquantifiable as well as a quantifiable quality. The successful integration of these quantifiable and unquantifiable goods into a whole is one of the conditions of a good life, and successful integration is possible if we can solve the basic methodological problem of ethics, that is, the problem of how material and nonmaterial, normative and non-normative claims are to be recognized as independent from, but at the same time intertwined with, one another.18
      The problem of determining how scarce goods can be distributed in the best possible way in order for the good life to be achieved by all members of society is a problem of moral economy.19 Regional and global markets, with their respective operating mechanisms, do not necessarily guarantee a fair and equitable distribution of goods to everyone. The basic methodological problem of ethics, i.e. the problem of determining how indivisible, incommensurable, and indispensable goods are to be connected to divisible, commensurable, and dispensable goods in order to form a social whole, presupposes that in constitutionally governed, democratic societies there are collectively generated goods that serve the welfare of all members and that can accordingly be justly and fairly distributed. However, the basic methodological problem is only solvable if not only gains in, but also losses of goods are fairly distributed.20
      Vossenkuhl proposes two maxims that can be used to solve the basic methodological problem. The first maxim is: a normative claim is changed when it leads to a distribution of goods that cannot be accepted. The second maxim is: a quantitative distribution of goods is changed when it infringes on normative claims. The first maxim is called the “maxim of scarcity,” and the second maxim is called the “maxim of norms.” The second maxim is an essential correlative to the first, because if the first maxim alone were applied, normative claims would, over the long run, be radically relativized, and would become meaningless whenever conflicts of distribution arise. On the other hand, the second maxim may be difficult to satisfy, because no normative claim contains a clear criterion of its own material infringement.21 Both maxims must be simultaneously applied in order for the basic methodological problem to be solved.
      Because inequalities in the distribution of material goods can be arbitrated but not abolished by the two maxims, they must be supplemented by a third maxim, the “maxim of integration.” This can be stated as follows: normative claims and distributions of goods can only be changed when neither absolutely indispensable goods nor the value structure of goods as a whole are thereby compromised.
      Vossenkuhl explains that a good life in a social whole is only possible if the goals of processes of distribution are cooperatively determined. The maxim of integration therefore has political consequences, because it requires that the claims of individuals and groups to indispensable goods be protected against infringement. The maxim of integration also corrects any morally unacceptable restrictions of normative claims and distributions of goods.22
      The maxim method of solving the methodological problem of ethics may not always make possible the good life; even if the method is correctly applied, the possibility of the good life is neither guaranteed nor exhausted.23 One reason that the maxim method may sometimes be ineffective is that the integration of goods into a social whole is a necessary condition for the good life, but not a sufficient one. Without a just distribution of goods and burdens, the good life is not possible, Conflicts between various group interests and political ideologies regarding the meaning of “the good life” may underlie failure to achieve just distributions of goods and burdens. Thus, pluralism, political compromise, and social cooperation are necessary.
     
      
FOOTNOTES

1Prof. Em. Dr. Wilhelm Vossenkuhl: Offizielle Homepage, online at http://www.wilhelm-vossenkuhl.de/vita/
2Ibid., at http://www.wilhelm-vossenkuhl.de/publikationen/.
3Wilhelm Vossenkuhl, Die Möglichkeit des Guten: Ethik im 21. Jahrhundert (München, C.H. Beck, 2006), p. 16.
4Ibid., p. 21.
5Ibid., p. 30.
6Ibid., p. 49.
7Ibid., pp. 66-67.
8Ibid., p. 84.
9Ibid., p. 121.
10Ibid., p. 132.
11Ibid., p. 140.
12Ibid., p. 236.
13Ibid., p. 236.
14Ibid., p. 240.
15Ibid., p 244.
16Ibid., p. 250.
17Ibid., pp. 251-252.
18Ibid., p. 296.
19Ibid., p. 346.
20Ibid., p. 347.
21Ibid., p. 352.
22Ibid., p. 377.
23Ibid., p. 417.