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Rubab, thanks for your excellent reply. I was unaware of the Ayushman Bharat program in India. I do not know of a similar program in Pakistan. What I hear often of the Modi government is that it extends favoritism to the majority and discriminated against the minority populations, but perhaps this is not the case with this program. With such a vast population as India has, the greatest good for the greatest number (utilitarianism) certainly involves a HUGE number of people. I appreciate your resonance with egalitarianism.
Your approach to addressing such egregious matters as human trafficking and organ trafficking by first looking at the inequities which lead to these practices and then to international organizations as a means to address them seems balanced to me.Pho, thanks for your input. I think your focus on primary care (and prevention) is the right focus for a move toward universal health care. That we in the US spend so much on end-of-life care and on treatments for preventable diseases is difficult to reconcile with at times paucity of resources placed in the areas of prevention. That fewer medical students are choosing primary care for a variety of reasons is concerning to me in the present US milieu.
I appreciate your focus on prevention. Considering the abject poverty of many parts of the world and the outrageously expensive nature of health care in HICs, it seems that the best for both worlds is a focus on prevention. It is best “bang for the buck”, but the ounce of prevention is certainly better utilized that the pound for the cure. I also appreciated your focus on the value of field experience. It was much easier to move forward a bright and eager worker in Pakistan than it is in the US because we didn’t have so many regulatory and training criteria to meet there. My experience in the US is that without degrees and certifications, one is unable to perform many tasks in the health care arena.
Ronisha, thanks for your thoughts. It is an admirable goal for even “high-quality care” to be covered in universal health insurance. Having worked in extremely poverty-stricken rural Zimbabwe and having my father recently hospitalized in the US, I can hardly get my mind around the incredibly high expense of my father’s care and the unaffordability of even basic primary care in Zimbabwe. I suppose a starting place would be to try to insure basic health care and then try to move forward.
Bethany, thanks for your comments. I have to admit, considering the fact that so many parts of the world are at war, the idea of international cooperation for some semblance of universal health care on a global scale seems a far shot. I would speculate that all nations are somewhat “statist” in their approach to health care for their own. International cooperation has only existed through NGOs, philanthropic business ventures, missions, etc.and that has been limited in scope considering the vast needs of LMICs and the vast differences in health care resources of HICs vs LMICs. Countries such as the US, it seems to me, would have to accept the idea on a state and then, perhaps, national level before even considering the idea on a global scale.
Vincent, thanks for your great responses. I appreciate the fact that you were very comprehensive in your suggestions regarding the scope of UHC, including a focus on vulnerable populations, public health emergencies and even on travelers and migrants. These are very generous goals as most countries focus, even if poorly, on their own citizens with rare hospitality to the “foreigner” within. It is the difference between a “statist” approach and a universal one.
Austin, thanks for your reply. I appreciate your mentioning of the example of Cuba. I was surprised that the Cubans established a hospital in northern Pakistan after the 2005 earthquake, along with many other countries who came to help. That they have invested in global disaster management was impressive to me. I also really liked your mentioning of a possible role of CHWs at the time of hospital discharge. Such a system could be very helpful in multiple contexts, including that of the US. Another possibility for this type of role would be that of parish nursing.
Jasmine, thanks for your responses. I appreciated the way you brought up the example of Nepal, which highlighted the participation of the community, and the importance of addressing issues of inequities in coming to a universal health care system. I also noted your mentioning of what you noticed in your time in the military. During my years in Pakistan, it was noted that many health care workers joined the military or government hospitals because of the issues of potential job security or benefits.
Kainey, thanks for your responses. You have mentioned physical and psychological risks but what about the ethics of this request. Is it ethical to remove a healthy breast for this reason – why or why not? If it unethical, is it right for you to refer her to someone who would do the unethical procedure? These are the questions I would like you to grapple with.
It is good to have brought up the Chinese Communist Party policy. I think that what you are referring could perhaps be referred to as a “utilitarian beneficence” – the greatest good for the greatest number. That is one interpretation of ‘the good’ (as determined by the state), but as you mention, does not take into consideration the other aspects of ‘the good’ as spelled out by Pellegrino.Alexis, I’m glad to see you grappling with these questions. In the first one, you see the danger of everyone seeing the “good” in a different way. This is the problem of pluralism, what Englehardt addressed in our first set of readings. Bioethics post foundations. It is also is why virtue ethics, which we unfortunately haven’t talked about in our class, was so important prior to the 1960s. Part of professional formation for doctors included virtue, which requires examination of the “Good/good”, examination of oneself and one’s motives and the cultivation of habits which would enable one to choose “the Good/good”. This was seen as a way of insuring the best outcome for the patient. Without virtuous physicians, the likelihood of twisted good was greater. People like Pellegrino want to recover this emphasis on virtue.
About the second question, I think the matter goes back to Kass and the telos of medicine. Kass would say that the purpose of medicine is to maintain the excellence of the body and to restore the body to it’s natural excellences. The breast is part of the excellence of the givenness of the body (including this female patient’s) and thus, we respect that excellence and don’t remove it because of her wishes. Twisted teeth maybe are not excellent and straight ones are?:)Shajin, I like your eagerness to help this lady improve her golf swing in other ways! Assuming she is somewhat educated and has thought through the medical implications of this and the fact that it is not a danger to “her overall health and well-being”, I wonder how you would carry the conversation further. What is good “overall health and well-being” as it relates to this woman’s request? Suppose it was proven that the left breast removal improved the range of motion of the left arm such that a golf swing could be improved and she was willing to take the proven-to-be-minimal surgical risks? How would you spell out your ethics to justify a denial?
I am interested in the story of the HPV vaccine trial that took place in India. Perhaps you could share it with the class tonight.Sarah, thanks for your replies. In the first response you are seeing a limited view of beneficence as utilitarian beneficence – the greatest “good” for the greatest number. I think Pellegrino attempted to delineate different types of “good” realizing that ‘beneficence/good’ needed to be further clarified because of the breadth of it’s meaning. Utilitarian or communal good would be one of those meanings.
In the second question, I appreciated the fact that you realize that the only “good” in choosing to go through with the patient’s request relates to her perception of her own good. You have called this into question by bringing up the possibility of body dysmorphism. I think the “moral status’ of the body, the confused anthropology in the case of this patient, is key to thinking clearly about this case. It seems as though you might lean into trying to redirect her thinking to see her “body design” as something other than something to simply be technologically manipulated for the purpose of something like a better golf swing.Thanks, Rubel, for your well-structured and thorough response to question #2. It seems that the dialogue you envision with this patient could help clarify why you think and choose to act/not act while also respecting her as an autonomous chooser (part of the “good of the patient as a human being is the human’s ability to make choices).
Regarding question 1, I wonder if it is possible to see things like respecting the autonomous choice of a patient, not doing harm to the patient and make sure the patient is treated justly, can somehow be subsumed under the category of beneficence – with beneficence as foundational. I suppose it depends upon how limited the scope of beneficence is seen to be. I think Pellegrino was attempting to broaden the scope of beneficence by looking at the four types of good in order to hold it as foundational. If we think about a relationship with someone we love – it seems that one way to see our love is that it certainly does not harm, respects the other’s views and insists on justice for the loved one. If there is a weakness, it would be because we have a weakness in our love (or aspects of our love) for another. We didn’t have time to get into virtue ethics, but someone like Pellegrino would say that the development of virtue is of paramount importance in the professional so that his/her love (beneficence) is not lacking in its full breadth. He very much bemoans the loss of talk about virtue in modern professional formation.Gracie, thanks for your responses. I appreciated you mentioning simulations. I found myself thinking of the well-equipped “SIM center” at our medical school which the students visit for learning procedures. Would that we could have something similar for cultural competency which could be visited and engaged in over the course of the student’s time while in school. It would be an effort to incorporate the topic consistently into the curriculum.
Bethany, I appreciated your making the distinction between fixed concepts presented in a classroom and relationships lived. Relationships with patients (like any relationships) are more like a moving river with an unfolding of the story as time goes by, even within an encounter. I thought of my relationship over the last six years with five Afghan refugee kids who have been in foster care. The story of their lives continues to unfold and the joys and challenges that I am walking through with them continue to develop. In is in this process that I am learning competence (or, at least I hope I am!).
