hey as you can probably tell I'm not feeling so good so I'm gonna be doing most of today's episode from right here I've got my lemsip I've got my chimpanzee let's talk about a health care part one personal responsibility in my country the UK we have free health care at time of recording unless here one of the several million people for whom it isn't actually free and every now and again there's a story in the news about some medical group restricting the care they provide to patients who are very fat or who smoke there was a famous one a few years ago the Vale of York Clinical Commissioning group said that patients who have BMI is over 30 or who smoked will have to either lose weight or quit smoking before they can undergo elective surgery and Eclair folks in The Times recently so that we need to start thinking about deserving and undeserving patients one of the principles behind ideas like this is that people who are in some way responsible condition should be denied the health care they need or deprioritized for the healthcare they need as the best way of achieving max the result being that they would have to live longer with suffering that could otherwise be alleviated more quickly when it comes to who should get health care the classic examples philosophers like to talk about are things like should smokers get lung transplants or should alcoholics get liver transplants and whenever these discussions arise there's an idea often floated called the principle of voluntary responsibility even if you haven't heard the name you've probably come across something like it before it goes like this let's say you decide to smoke why not it's addictive and it feels great but after 40 years of cigarettes you have cancer and you need a double lung transplant or you're gonna die but so does Jemima Jemima has cystic fibrosis there's a condition that affects the lungs its genetic she was born with it she did not make any voluntary decision that got her here unlike your voluntary decision to smoke and wouldn't you know it there are only enough lungs for one of you if you haven't decided to smoke all those years ago she would have just gotten the transplant but because you now need those lungs to her future is in jeopardy we're gonna have to enter some kind of decision-making process so there's a chance Jemima might not get those lungs you've put her at risk by creating demand for limited medical resources the philosopher Jeff McMahon thinks that you have a moral duty to make sure Jemima gets those lungs before you do that's the principle of voluntary responsibility if you make a voluntary decision that puts somebody else in harm's way you are on the hook for getting them out of it but man thinks that it is right for smokers to be denied lung transplants if there are other people waiting and that we could extend that principle to other people as well to a lot of people that sounds reasonable at first especially in the UK and the USA where personal responsibility is a big tenet of political and economic philosophy yeah if you get sick and it's your fault then why should somebody else suffer just so you can get better but here's the kicker smoking can be substituted for any medical condition that somebody develops as a result of making any voluntary choice and lungs can be substituted for any medical resource including money and time if there are enough lungs for both you and Jemima but only one surgeon or only enough time in a day to do one operation then Jemima gets them every time and Jemima with her cystic fibrosis can be substituted for anybody with any medical condition that they develop through no choice of their own if you need a lung transplant because of your smoking but somebody else gets shot in the kidneys and requires a completely different kind of procedure well still you cannot get any treatment until they are completely fixed that's a logical requirement the principle of voluntary responsibility has no room for half-measures and arbitrary decisions this principle is so much more demanding than a lot of people realize the philosopher down whittler points out that if we really committed to this we would deep prioritize healthcare for every single case of sexually transmitted infection every single case of AIDS and every single pregnancy except in cases of rape or infected blood transfusion because those are all cases in which somebody needs healthcare as a result of voluntarily choosing to have sex so all the cystic fibrosis patients have to be seen first every attempted suicide who comes in would get left in the corridor maybe even stuff like food poisoning you chose to eat shellfish rather than a veggie burger you knew the risks and again when I say these would be deep prioritized I mean that funding for them would be entirely removed until every single non voluntary healthcare condition was completely fixed if you're pregnant you cannot receive a single second or penny of medical attention until cancer is cured if you believe in the principle of voluntary responsibility that is what you are logically committed to so things get pretty unrecognizable pretty fast if we start allocating health care based on who we think is responsible for their own condition you might also be wondering just on a practical level how can we even tell to what degree somebody is responsible for the state of their health and it's funny you should ask that because part two just on a practical level how can nobody ever seems to talk about applying the principle of voluntary responsibility consistently or completely in the UK at least it always seems to come down to smokers and fat people so why well part of the story is that it's to do with risk especially if we're talking about surgery all surgery carries an element of risk it's the last legal blood sport in England as the surgeon once told me and if you are very fat until you smoke that can correlate with other conditions that could mean surgery carries greater risks for you than it would for somebody who didn't have those other factors the medical term for other factors like that is comorbidities but that prompts the rather interesting question of how do we measure risk when it comes to allocating healthcare resources a study in the journal bioethics asked subjects to look at fictional patient files and decide who should get organ transplants in cases when there weren't enough organs to go around the authors asked 283 people which they admit is not a representative sample size of the public to decide who should get a heart transplant between patients with or without histories of smoking with or without histories of intravenous drug use and widow without histories of eating high fat diets against a doctor's recommendation subjects were significantly less willing to distribute organs to intravenous drug users than to cigarette smokers or people eating high fat diets even when intravenous drug users had better transplant outcomes than other patients subjects allocation decisions were influenced by transplant rock gnosis but not by whether the behavior in question was causally responsible for the patient's organ failure people's unwillingness to give scarce transplantable organs to patients with controversial behaviors cannot be explained totally on the basis of those behaviors either causing their primary organ failure or making them have worse transplant prognosis instead many people believe that such patients are simply less worthy of scarce transplantable organs it is not uncommon for people to argue in favor of allocating resources on the basis of personal responsibility what our study shows is that these arguments may be convenient ways to support what otherwise merely reflect social desirability judgments in other words when human beings make decisions about who should get health care we might be vulnerable to making those decisions based not on how much good could be achieved or on the risk but on who think is deserving I say might be vulnerable because in fairness that is only one study and it has its limitations like the sample size it only investigated behaviors like drug use and smoking as well it didn't investigate how things like gender or race might impact healthcare decisions in her book fatal invention bioethicists Dorothy Roberts laments that black and Latins patients in some studies have been shown to be under prescribed pain relief compared to white patients with similar conditions and to wait longer for emergency treatment although that study I quoted did investigate how subjects view people who have high fat diets it didn't investigate how they view fat people specifically fat people are discriminated against in employment in education and even in court being fat is stereotypically associated with being lazy and slow and unintelligent it's assumed to be your fault as if a being fat is a problem and be social factors like access to what sorts of diets are available for who just aren't a thing sources for all of that in the doobly-doo and thank you to Kevin Bay on Twitter for introducing me to the world of fat studies in her book heavy communications professor Helen sugar examines the various ways Anglophone countries talk about fatness and obesity the contradictions and implications of the various discourses surrounding it including the ones that lean heavily on personal responsibility as well as the downright myths and junk science what she highlights is that these questions defy simple answers not only or even primarily due to complex and still unfolding science but because fat and accordingly obesity can only be understood indeed can only mean anything at all within the historical and cultural context in which they occur intervention in cultural or health issues cannot ever simply be about the facts whether because those facts are themselves a cultural product or because the facts are bad but the flipside of the personal responsibility argument might be that even if we can't tell exactly how responsible somebody is for what or even whether that idea actually makes sense I know a free when I see one and I don't want my tax money going to support somebody who's just gonna waste it on self-destructive behavior but if that's your stance then I understand but I don't really know how to argue with you on that one because I do want that I'm okay with my tax money what little of it there is admittedly going to support somebody who is sick regardless of whether they are responsible for their condition assuming that idea even makes enough sense to be practically useful because I just think that healing the sick and helping people is a good thing to do even if you aren't religious and I'm not religious either there is a reason that people used to think healing the sick was a sign of divine deliverance it sucks being ill it consumes everything else in your life you can be the richest person in the world but if you don't have your health you're gonna be miserable it sucks having to go to a hospital and if I can lessen the amount of time that anybody spends in that situation then I guess I just think I ought to do that part three context and power I'm gonna use a little bit of post-modernism here so will you Jordan Peterson fans out there put your earplugs in now the French philosopher Michel Foucault said that in the old days political power used to control the bodies of individual people it would publicly execute you brand new or torture you if you disobeyed the rules nowadays though it controls the bodies of groups of people through what he calls bio politics which includes things like public standards of Hygiene public vaccination programs and of course funding for healthcare rather than dealing with the individual buyer politics deals with the population as political problem and there's an interesting tension there between the bio political standards to which whole populations are held and the often very individualistic personal responsibility angle with which we on the ground are expected to engage with health care providers at its best this expansion of power and Tobiah politics produces things like public vaccination programs which help save life at its worst it produces things like people with deafness being banned from learning sign and women being banned from getting abortions fuko's point is that power is never neutral in the norms that it appeals to no biopolitical decision about who gets health care can ever be unbiased can ever be immune to fatphobia transphobia ableism classism racism and whatever because as sugar notes any appeal to the medical facts presumes a certain context in which those facts matter thank you for rejoining us Jordan Peterson fans there was only a small dose of person modernism so you should be okay just as a precaution though you probably shouldn't actually read any philosophy for at least 24 hours after this so you probably fine right you might be worried about the ways in which power can creep into discussions about healthcare like Ted Cruz he's worried that a system like the one we have in the UK gives the state power over human lives trouble is though that's kind of what states do unavoidably and mr.

Cruz can give us a great example of this Ted not only believes in the death penalty just as part of his political life but as Solicitor General for the state of Texas defended the state's right to execute its citizens on five occasions now whatever else you think of the death penalty you've surely got to admit that it is definitely the state having power over human lives and even in a country like mine where we try not to directly execute our citizens the government still has power over human lives because that's kind of what a government does so rather than deny that power is there I think it's more fruitful to talk about what flavor of power it is there are all kinds of background factors that shape power and how it operates but as a raging leftist SJW I'm particularly interested in the political economic factors the political economic context in my country the United States and many other countries besides is neoliberalism an economic philosophy that not only loves free markets and individualism but also uses the state to to them for neoliberals freedom for humans means freedom of the markets and the ideal subject is an individual isolated consumer I've discussed neoliberalism in more detail before you can see that video by clicking the card that's just appeared in the top right the construction of choice where choice means a free market is key to neoliberalism and it's how it spreads from being a political economic philosophy to a force that shapes our lives and even ourselves you might have seen some American political commentators talking about how they worried a free healthcare service would deprive them of the right to choose their providers chuga rights neoliberalism ascribes virtually all responsibility for personal and social welfare to the individual which is further articulated as crucial to individual liberty under the auspices of choice importantly this choice is tightly linked with consumption to the extent that individuals are expected to choose with their dollars and thus customize priorities and goods and services to the ends of realizing them that matter to them in this way exercising their individual choice is articulated as tantamount to democracy under this framework the practical role of government is to facilitate the market moreover government intervention at any level in the form of social services for instance or with respect the regulation of industry is represented as cultivating or enabling dependence and more to the point undemocratic thus hampering if not denying individual liberties and aspirations of course it's also true that these free markets are great at making rich people richer and we might wonder what that choice really amounts to especially if you can't afford health care at all these concerns profit politics choice are important forces that shape the context of health care discussions and that's why there's never really any serious discussion about applying the philosophical principle of voluntary responsibility to its fullest extent because it isn't really about resource management or personal responsibility it's about power managing bodies as an example in my country healthcare discussions are often deliberately held in the framing of what the NHS can afford but the NHS could afford to look after everybody that is the thing that we could do just like we could house every homeless person there are more empty houses than there are homeless people it's not a question of there not being enough resources we don't do it because we choose not to and the same is true of health care limited resources are often limited artificially by the choice to lower taxes to permit corporate tax avoidance or to just spend that money on other stuff and whether you think that choice is ultimately for the best or not depends on your political conscience but in a very wealthy country like mine or in the United States who gets healthcare and where resources are distributed is a question of choice not of scarcity and so we cannot avoid discussing the values that will guide that choice patreon.

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