Thursday, March 15, 2012
The following is my reply to two comments posted by MOJ reader Andrew Mackie-Mason in response to Part 1 of my post on the HHS Contraceptive mandate here. A portion of my original post as well as Andrew’s comment and my reply concern the meaning of “health” and “healthcare.” This conceptual disagreement is part of the basis of the controversy over the HHS mandate and is the source of a wider disagreement in bioethics. I hope that readers find it to be of interest.
Thanks for the post and for taking the points I was (and am) trying to make seriously. By way of response, I have a few questions for you – questions I believe that Matt Bowman and other readers likely share.
First, you suggest that the understanding of “health” that I put forth, as a scientific term with an objective meaning, is mistaken and should be replaced with an understanding of “health” as autonomy that has only a subjective meaning. That is, you argue that “health” is “what each person sees as the proper functioning of their own body as an integral aspect of their self.”
You are of course free to advocate for this position, and you may truly believe that this subjective approach is correct, but you should be prepared to see and embrace the full implications of this view – you should be prepared to follow your argument where it leads.
Thus, if “health” is a subjective determination – a matter of personal autonomy – then you should be prepared to require physicians and hospitals (i.e. “healthcare providers”) to engage in assisted suicide – whether the person is young, old, or middle-aged; suffering from a debilitating, terminal illness or “the picture of health.” Similarly, if “health” is subjective – a matter of individual autonomy – then “health” would seem to include every imaginable kind of plastic surgery, no matter how frivolous or self-indulgent it may appear to the outside observer. Such a perspective is irrelevant, indeed, obnoxious to the concept of “health” that you put forth.
What is more, if autonomy is the touchstone of “health” then you should be prepared to require physicians and hospitals to perform “voluntary amputations” – that is, amputations on individuals who possess healthy limbs (sorry . . . it’s hard to avoid use of the term that doesn’t carry an objective meaning) – that is, limbs that are not diseased or somehow impaired but fully functioning. That is to say, in the case of voluntary amputation, there is nothing wrong with a person’s hand or leg – he or she simply wants to be rid of it.
Now, traditionally, this sort of desire has been seen by the medical profession as a severe pathology and that it would be profoundly unethical to assist an individual in achieving his or her desire to have a limb removed. Although some in the medical field now wish to explore this phenomenon and others even wish to assist these individuals by performing the requested amputations surgically, many continue to see this desire as pathological and the proposed amputation as conferring a disability on the individual (see here and here). Your understanding of health would seem to leave no room for this traditional view. Your view would, it seems, mandate that our healthcare system embrace the subjective desire for loss of limb as a dimension of “health.” Are you prepared to argue for this?
Second, you responded to my characterization of health with respect to the conjugal act in human beings as relying on a “fuzzy teleological objectivism.” Now I understand why you might wish to do so for rhetorical purposes, but are you prepared to do so on a substantive basis? If so, am I correct in assuming that you would wish to characterize the process of providing the body with nutrition – the consumption and digestion of food – as likewise relying on a “fuzzy teleological objectivism”? If so, you must do more than garnish a rhetorical flourish followed by a confident Q.E.D.
The reason why I offered the hypothetical involving a pill that would induce nausea and vomiting that would be marketed to bulimics was precisely to pose this challenge. You ignored this hypothetical in your response. The teleology of the digestive system (not to mention the circulatory system, the pulmonary system, the nervous system, the lymphatic system) is hardly fuzzy. Indeed, you won’t hear that kind of derisive talk concerning bodily functions in medical school. Many physicians today may (sadly) be ethical Nietzscheans, but when it comes to their ontology, they remain committed Aristotelians. The problem that many encounter today (and I would suggest that this is your problem as well) is trying to fit their ethical commitments inside their scientific understanding of “health” without eviscerating the latter.
Now, on your account of “health” as autonomy, the hypothetical pill would seem to be unproblematic. Indeed, if a person wants to control her weight and her body image in this way, taking the pill makes perfect sense. Of course on this account bulimics are “healthy” people. Are you prepared to argue that this is the case? If not, I think you will find that invoking some kind of objective standard – a standard based on how the body functions – to be unavoidable.
Third, you say that there are vaccines that “don't fix any problem in the body,” vaccines that “don't cure a disease or disorder.” What vaccines do you have in mind?
All the vaccines I can think of are true forms of preventive medicine in that they prevent the body from contracting a disease by aiding its resistance to polio, or whooping cough, or German measles, or some such malady. And in this regard vaccines are decidedly unlike contraceptives. These vaccines do not impede the natural function of the human body, they augment it. They stimulate the body’s own immune system in defense of the body against some infection that would harm it, perhaps even fatally.
A contraceptive may “prevent” something (sometimes after the fact!). Again, on your account of “health” based as it is on a subjective determination of the individual, pregnancy would or would not constitute a “disease” and thus an impairment of “health” based upon whether or not the pregnancy was “wanted.” On this same account, however, polio, pertussis or rubella would be a disease only if the person who contracted it didn’t want it. Likewise, a fully functioning eye, hand, liver or kidney would or would not be “diseased” based upon the person’s desire to retain it. Are you prepared to defend this point of view?
You note that some people decide to forego receiving vaccines due to the risk of side effects and others do so for moral or religious reasons. With respect to the former, you say that “it would make perfect sense for someone to weigh whether the lack of functionality in their body was worth the risk/side-effects” such that “[v]accines for willing patients are clearly health care, [whereas] vaccines for unwilling patients clearly aren't.” For you, what distinguishes the two as such – that is, as healthcare – is the subjective evaluation of the individual.
This is not correct. A vaccine is a form of healthcare – the benefit of which is prospective and often accompanied by risk – risk that one’s body may be impaired as a result of the vaccine. That is, the judgment on whether or not to receive the vaccine is based on the function of the body and the risk calculation that this function will be impaired. Thus, it is not necessarily the case that the same vaccine is or isn’t healthcare based on the subjective judgment of the individual. Rather, it is entirely consistent with “health” understood as a scientific matter that the vaccine is healthcare that some individuals chose to forego based upon their assessment of the risk to health as objectively determined.
Of course a subjective judgment may enter into the decision not to receive a vaccine. But such a decision does not alter the status of the vaccine as “healthcare.” It is not the case that a vaccine is or is not “healthcare” depending on the moral or religious objections of the individual. Rather, the vaccination is healthcare that the individual chooses to forego based on other values. There may be many good (perhaps even compelling) reasons to honor these values, but doing so doesn’t alter the meaning of “health.”