This is bioethics bytes with me, David Edmonds and me Nigel Warburton.
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You imagine the following choice. You can either finance medical treatment that was thought hearing to 50 people who'd lost hearing in just one ear.
Or you could pay the same amount to treat an entirely deaf person so that this one person could hear perfectly.
Which would you choose to help the 50 or the one?
In this series, we've mainly focussed on dilemmas and debates involving individual doctors and patients.
Jonathan Wolff is a political theorist and he believes that traditional bioethics misses a vital dimension the distribution of resources.
Joe Wolff, welcome to Bioethics Bytes. Well, thank you for having me.
The topic we're going to talk about is political bioethics, in a sense, as a new subject.
Could you just say what it is and how it relates to traditional bioethics?
Traditional bioethics has focussed on what goes on in the hospital or in the GP surgery, a whole series of doctors dilemmas as they've been called.
What should we tell the patients? What can we release to the patient's family?
What should we do with the patient's organs after surgery?
What should we do at the beginning of life? Should we save the baby or not?
What can we do at end of life? Can we legitimately engage in euthanasia?
Those are all very good questions, but they're all about the doctor's relation with the patient or sometimes with the patient's family.
The type of thing I'm interested in which we've called political bioethics,
or some people call it population level bioethics, some people will even call it public health.
Ethics wants to widen the focus to make very clear there's a lot to do with health that is not about what goes on in the hospital or at the bedside.
And these other issues also throw up moral and political dilemmas.
Perhaps you could give a couple of examples to show us what we're talking about here.
Consider what drugs should be made available on the NHS.
This is a question about health care, but it's not a question about who should give consent to an operation or what should be told to the patient.
It's much more like traditional questions and political philosophy where we're talking about issues of justice and fairness.
What drugs should be available? Why should they be available? Who should they be available to?
These are questions about health, the moral questions, but they're not questions of a traditional bioethics form.
And what about the more general issues of health that go beyond medicine?
Do they fall within the scope of political bioethics? One thing within this literature that's very important is to make a distinction.
You could call it a distinction between health and health care or the distinction between health and medicine.
Most of the things about your health have got very little to do with the health care system.
That is what makes you ill is not anything to do with your doctor.
It's your lifestyle, your genes, bad luck and so on.
So the things that are needed to keep you well very often have got nothing to do with the medical profession.
If you take a longer historical look, the rise in life expectancy we've had in the last hundred years is really incredible.
People are living decades longer. Why is that?
Now a lot of people will say it's these fantastic advances in medical care.
We can now do heart transplants, all sorts of operations that we couldn't do 100 years ago.
But how many people get a heart transplant? How many people have had these operations?
The reason why life expectancy is increased, a lot of people think, is because of much more basic things like sanitation, hygiene, nutrition.
These are now known as the social determinants of health, the factors in your life that determine your health.
Medical care is one determinants of health, but in fact, it turns out for most people to be a very small component.
So political bioethics tries to take the bigger picture.
It doesn't just zoom in on doctors dilemmas or individuals dilemmas about how they should react to the available medical resources.
He's looking at a whole range of topics that perhaps have a larger effect on your likelihood of a healthy life.
Absolutely right. I mean, one of the most important documents really in generating this, it's quite old now,
but it was the Black Report in 1979 looking at the progress of the National Health Service.
National Health Service came into effect in 1948. 30 years later, what effects did it have?
And when the NHS came in, everyone thought that it would be fantastic.
It would equalise health or at least improve the health of the worst off.
People who didn't have access to health care. The Black Report pointed out that health of the nation had improved,
but most of those improvements had gone to people who were already well-off and who already had good health.
And it argued that the social determinants of health, poverty, poor working conditions,
poor housing hadn't really changed very much for people at the bottom end, so they were still getting ill.
Now, one of the authors of the Black Report argue that because of this, we ought to spend less money on health and more money on poverty alleviation.
Therefore, for reasons of health, take money out of the health system and spend more on social services.
Naturally, that didn't go down very well with his colleagues on the committee, and they didn't make that recommendation in the end.
But every now and again, this same point is made.
But that's a fascinating case, because that is, it seems to me, a rigorous application of cost benefit analysis.
If you're really concerned with the outcome that health is improved, then there might be better ways and pumping money into health service.
That's true. And that was the argument. It was also realised that policy doesn't always follow the cost benefit analysis because that
can be very powerful political actors who will make sure that the interests and looked after,
even when they may not be indicated, is the best policy.
But as philosophers, we're interested in thinking clearly about how in this case, resources might be well allocated.
What sort of principles should we use then? Are you saying that it's wrong to do cost benefit analysis,
or that so far people who've done cost benefit analysis have focussed too narrowly on one little bit of the picture?
Cost benefit analysis is going to be essential when you've got a fixed level of resources,
or at least a limited level of resources, as we already have.
In fact, raising this issue does bring us to one of the most interesting and lively areas in political bioethics, which is the role of Nice.
There's a National Institute of Health and Clinical Excellence because they have the job
of deciding which drugs are going to be made available on the National Health Service.
And what will happen is that a pharmaceutical company will create a new drug.
It will go through the normal safety and efficacy procedures to test that it actually works and doesn't kill people.
So there is a point where it's licensed in the sense of being available, but it might be very expensive.
There are all sorts of drugs that come forward and the drug companies want the National Health Service to take them.
A decision has to be made and the way that's done at the moment is through not exactly cost benefit analysis, but cost effectiveness analysis.
It's assumed that there is a certain drug budget, perhaps £10 billion a year in this country.
And roughly speaking, the job of Nice is to work out how to get the best health benefits for that 10 billion.
That will inevitably mean that they won't licence for refund on the NHS some drugs
that are very expensive because they don't think they give sufficient health benefit.
Could you just explain what the difference is between cost benefit and cost effectiveness?
Cost benefit analysis requires you to give a valuation of the costs and evaluation of the benefits and
then to pursue a course of action where the benefits are higher than the costs to the highest degree.
So this requires monetisation of all values in order to do that.
Cost effectiveness doesn't require so much information.
Suppose you're doing your shopping and you've got a fixed amount of money in your
pocket and you want to go out and get the most nutritious shopping you can.
You can make decisions between different things, and you could end up with one trolley,
and you could look at that and say, I'm sure I could have done better with this money and go back and change a few things.
You could be sure you've made the most cost effective use of that money without having a view about the value of the benefits.
That is, you haven't said, well, ten calories is worth five piece.
I've got to make sure I've got that much. So you haven't really worked out whether the benefits outweigh the costs.
All you've done is spend your money in the most effective way you can, and that is what the health system at the moment does.
And the currency, it measures effectiveness and is quality of life.
Yes, primarily it uses a notion known as the quality,
which is the quality adjusted life year to people who come across it the first time, including me.
It seems very crude and inhumane measure, but what it does is say,
suppose you were to live for the next year in full health, no health problems at all.
Well, that gives you a quality adjusted life. Year of one.
You're getting a full year. So 1.0. But suppose you had some impairment.
Suppose you had a problem for some reason with mobility and you couldn't get around very well.
Perhaps you've got arthritis, perhaps you've had a sporting injury, so you're not in full health, so that next year will be less than 1.0.
What would it be? Well, it might be 0.8 if you're blind.
The current view is that gives.
You quality adjusted life year, your next year will be worth 0.5 qualys because there's still an awful lot you can do if you're blind.
It seems devastating, but there's still a life to be lived with lots of satisfactions.
If you're blind and bedridden, that might then go down to 0.2 and so on.
And there are states that are thought to be worse than death, quite a few states worse than death.
So they have minus quality numbers. So to put it in its crudest form, what nice does, and I'm going to modify this in a moment,
is trying to get the most quality as it can for the health budget.
And it charges new medicines on on the grounds of whether they're going to deliver more qualys than other things that are currently in the system.
So that's a way of assessing what kind of drugs should be available to people who need them.
What could be wrong with that? That seems to be quite a rational way of allocating resources.
Well, it's true. It does seem very rational, and for many purposes it is.
But what as a philosopher jumps out when you start to look at it, is we have a system.
A certain amount of money is being used to maximise the number of qualities available.
That sounds like a moral theory called utilitarianism.
And the first thing we learn in our undergraduate classes is utilitarianism is wrong.
Now, we might be wrong to be told that utilitarianism is wrong,
but the standard method of decision making in health economics at the moment uses what many people believe to be a flawed moral theory.
This is interesting in lots of ways. One way is that it allows us as moral and political philosophers to draw on
what is now a vast literature to try to illuminate questions in health policy.
We could go back and say what we wrong. Actually we over hasty to dismiss utilitarianism should have been utilitarian after all.
Now to know whether that is right or wrong. In this case, what we have to do is think about the possible consequences of maximising qualities.
One type of case that has been used in the literature is so-called discrimination against the disabled.
Now, I mentioned before, if you're blind, your quality value for the next year is only 0.5.
If you're not blind, potentially it could be one. Suppose we were allocating the next heart for transplants on the basis of the quality value.
If you were going to give it to someone who's blind, the most you can get from them is 0.5 per year for however many years are going to live.
Whereas if you're going to give it to someone who's not blind, maybe you'll get them back up to one.
So if you were really going to use qualities in clinical judgement, people with chronic, longstanding health problems would get very little attention.
Perhaps a rigorous utilitarian would say that's difficult to stomach, but that is actually given the scarce resources, the best thing to do.
No doubt many utilitarians would swallow hard and say that in practice, actually,
things are not as bad as this because quality calculations are never made in clinical judgements.
They made it to a different level, made at the level when Nice is deciding whether a drug or treatment should be made available generally.
So in practice there wouldn't be any of this direct discrimination against blind people or others.
But it is true that under current situation,
a treatment for a patient group of poor health will yield fewer qualities than a treatment that could bring people back to full health.
And this has troubled a lot of people because if you think about it in your own intuitions about cases,
you might think people in poor health should be the highest priority for treatment,
not the lowest, even if the benefit you can give them is not as high as you could give to someone else.
So this is a typical objection to utilitarianism applied to the health domain.
So how do we get out of that? The first thing to do would be to look at other philosophical theories, because after all,
the development of moral and political philosophy didn't end with utilitarianism.
People came up with forms of rule utilitarianism later on with John Rawls.
Although, of course, John Rawls didn't talk about health care, his theory can be applied in this area.
His difference principle that we should make the worst off as well off as possible
can be interpreted in this area as a principle to give priority to the worst off.
The trouble with doing this, and I think this is one of the reasons why Rawls didn't talk about health care,
is that if you use the Rawls in principle giving absolute priority to the worst off, you have what has come to be known as the black hole problem.
You may have people who are very badly off, very expensive to treat and can get very little benefit from it.
And if you really believed an absolute priority to the worst off,
it seems that we would have to give all our resources to those people who are very badly off, even if this gave them very little benefits.
And this wouldn't be considered cost effective in other ways.
So people who use Rawls in type ideas have tended to hang onto this notion of giving priority to the worst off, but not absolute priority.
So a cynic listening to this might say. Well, these are very difficult problems, but philosophers haven't found a way to answer them.
They just present us with further problems. They reveal to us the consequences of certain strategies for allocating resources.
But where are the solutions? Well, I may well be one of those cynics myself.
I think it's going to be very hard to demonstrate that one of these is the correct approach,
is that we should be utilitarians or we should believe in equality or priority to the worst off.
Some philosophers think if you only think hard enough, we're going to be able to get to the right single true answer.
Others, such as Norman Daniels, have said that there are incommensurable values here,
and what we need in the end is a procedure that everyone can sign up to rather than a set of principles.
So Norman Daniels has what he calls the notion of accounting for reasonableness.
And this is very interesting. It has been adopted by Nice in this country.
So they say that they're not these crude, vulgar utilitarians.
They're not just trying to maximise qualities. They're taking other things into account, for example, severity of illness.
They would be much more likely to approve a drug if it cured a severe illness rather than if it gave a mild benefit to very many people cheaply.
And you can imagine a situation where you get the same quality value by treating lots of people,
giving them a small benefit with treating one person and giving them a big benefit.
And Nice is prepared to take Savarese into account.
So it's not crudely utilitarian, but what it tries to do is to have a procedure where all these values and the reasons are laid bare transparently,
so it can explain its reasoning to other people. And if others think they've gone seriously wrong, it is subject to challenge.
So is that a kind of cancer history where you debates the particular case rather than impose a principle that fits every case?
There's a type of ideal of reason where we should have a principle that we can apply to every case.
This is the holy grail of philosophy.
Ideally, we want a principle that is as small as possible, maybe two variables in one relationship and universal coverage.
But we all know really that we're not going to get anything like that. It would have to be much longer, many more variables, exceptions and so on.
So in the end, you find that the principle has so many exceptions, it's no longer principle.
And what we're doing really is appealing to a whole range of values and seeing how weighty they appeal to us.
And quite often all you can do is hope other people share the same view about how weighty the different values are.
It's a form of case by case analysis. There is room for principles, but nothing is going to be determined fully by principles.
You can appeal to all sorts of different types of considerations. But I think it has something in common with legal reasoning.
So if you think about a court case, very often a case is decided because there's some very clear principle of law and it's all cut and dried.
But most of the time, cases go to court precisely because there isn't a clear principle of law.
Both sides think they've got an arguable case, and very often you can't really predict which way the judge is going to go beforehand,
although the judge has to make it look like this was the only possible decision he or she could come up with afterwards.
So they provide a set of reasoning. They employ new distinctions that no one had ever thought of before, and they find a way of getting to an answer,
which is, in a sense, objective, and it creates a precedent for future cases as well.
It's rational and it's transparent, but it's not applying a single principle in order to determine an answer.
And I think a lot of reasoning in life is much more like the legal model than the principle model and decision making.
Health care allocation, I think is like that, too.
Well, is there a role for a philosopher in that world, then, where you're just presenting evidence, presenting arguments on either side?
What can we do as philosophers? There's a lot we can do. Maybe not what we thought we could do.
We probably thought we could solve the problems by coming up with the best theory.
I no longer have any confidence that this is what we're going to be able to do.
But we can clarify patterns of reasoning.
We can make clear what values are involved. We can show what logical relations, different values may have to each other,
that if you believe in one thing, then you shouldn't believe in something else.
Now, I wouldn't want to say that only philosophers can do this because other academics,
intelligent people, can do it to some degree, and they already do to it.
But we have the advantage that this is, in a way, all we do and in this area,
like many other areas of philosophical training, is going to be very helpful.
But I've said this many times, I'll say it again, I'm sure.
But in this area of public life, what we need are people with philosophical skills, not philosophical theories.
Jonathan Wolf, thank you very much. My pleasure. For more information about bioethics bytes, go to WW dot practical ethics dot oecs dot ac dot you.
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