Week 1 Flashcards
Medical humanism
The central tenets of humanism are:
-the human beings matter that their wellbeing or suffering represent real phenomena
-the goal of human societies is to promote human flourishing
-science reason and understanding are a central means of achieving human flourishing
-all human beings are equally valuable
Medicine and other healthcare professions are relentlessly humanist
Our specific bent is to promote human flourishing through improving health
Modern discourse is now steeped in humanist principles:
-individualism and individual rights
-wellbeing
-equality, equity and social justice
And of course the NHS is a profoundly humanist statement that all humans regardless of wealth or status are entitled to the same healthcare, based on need alone
Competing worldviews
Humanism is not the only perspective prominent in modern societies: theism, ecocentrism, collectivism
Most societies endorse ideas of social or moral worth to promote prosocial behaviour but by a pure humanist reckoning, prosocial behaviours cannot alter your value
Other ethical perspectives disagree
- eg utilitarians might argue that having dependents makes one more valuable
Most of us are relatively reluctant to completely disown ideas of relative social worth eg criminals
Humanity
There is something special about humans any human is worthy of our moral concern
These ideas have been around a long time
Aristotle de anima: human soul 5+ergon use reason, sensitive soul (animals) 3 ergon move perceive desire, vegetative soul (plants) 2 ergon reproduce assimilate
Thomas aquinas: believed in a similar soul hierarchy to Aristotle
Held that humans were important as “rational animals” and on this basis they were worthy of moral concern
However this basis does not guarantee equality for humans- aquinas believed women were less rational than men and therefore subject to their authority and less important
Applying this principle more broadly what is importance of: children, those with learning disabilities, those with brain injuries preventing rational activity
Humanism and humanity
Humanism (15th century onwards)
-humans are important and valuable in their own right
-human fulfillment is of importance as is working towards the good of all
-the universe is material and may be understood through science
-human flourishing and happiness should be cultivated through study and application
-human lives are assumed to be of equal value
Humanist discourse
Achieved dominance in the aftermath of WW2 and the atrocities of the holocaust. The evil inherent in identifying some groups as less human and less valuable than others was unmistakable
Significant progress was made in pursuit of civil rights of ethnic minorities in most western nations in the decades that followed
Many humanist institutions were created in the aftermath- eg UN declaration of human rights (1948); ECHR (1950); the NHS (1948)
However were still a long way from a humanist world:
-rights are often tied to citizenship, the handling of refugees has become a flashpoint
-our economic system openly exploits the developing world
-misogyny is engrained and endemic with 90% of the worlds population holding prejudices against women and double standards based on sex
-disability driscrimination is still prevalent and disabled people have many barriers to the access of goods and services (ONS 2022)
-capital punishment still exists in several countries including USA, Iran, Saudi Arabia, japan, Somalia, South Sudan, and the democratic republic of Congo
Medicine is founded on values of humanism
But is uniquely confronted by marginal cases
-what is life
-how do we define what is human
—genomics, consciousness, social behaviours, empathy
Are all humans equally human
Sanctity
Possibly the broadest of definitions
Approach adopted by several major world relations
A deity has created humans and given them souls
Human life is therefore sacred in a way animal life is not and all human life should be protected
The nature of the soul has never been comprehensively defined and cannot be materially measured or established
Not every religion holds to this model
-paganism holds that all life is sacred not just human life
-Hinduism holds a hierarchy over animals but advocates non violence towards them, and some animals have special significance eg cattle
-Jainism will not allow violence towards animals even in self defence
-Native American belief systems hold that the soul is the source of life and thought, an immaterial essence- animating humans, animals and even plants
Sanctity limitations
Many humans do not believe this and linking moral status to religious beliefs is unlikely to be appealing to those who do not
Many of the same religions that advocate sanctity of life do not advocate for equality of humans eg believers> non believers, men>women priests> laity, faithful> sinners
Such belief systems have not protected from atrocities in the past
Moral status
6 grounds for moral concern:
-sanctity
-autonomy
-sentience
-personhood
-potentiality
-patient
Autonomy (kantian theory)
Kant believed that what made humans unique and important was their will- the ability to act according to the law rather than impulse or desire
The only thing with any intrinsic value is a good will- a will which acts according to a moral law
Since anything without a will (ie is not autonomous) cannot have a good will it follows that it has no intrinsic value
Therefore anything which is not autonomous has no intrinsic value
Limitations of autonomy
Few are the human beings who act invariably according to a moral law, and in any case moral laws can differ significantly
Many are the ways for a human being to lose autonomy, permanently or temporarily does this mean we cease to have intrinsic value
No ones will is incorruptable- coercion, threat, even torture can force a person to behave in ways they would not choose
Rationality is now believed to be an enlightenment myth- human decision making is complex and much occurs at a subconscious level
Sentience
What is a sentient being
“ the capacity to experience episodes of positively or negatively valenced awareness”
The ability to feel pleasure or pain
If a being is sentient then it has direct moral status, most animals are sentient
Therefore most animals have direct moral status
Limitations of sentience
Most people accept that animals are sentient
But not all to the same degree eg pescetarians
Sentience is not the easiest thing to gauge
Few people would accept equal moral status for animals and humans regardless of the capacity for pleasure and pain
Concepts of sentience change with time they are cultural
Up until 1987 doctors didn’t believe newborns felt pain
Personhood (or sapience)
It is being a person rather than being human that gives us moral worth
Related consciousness
Being a person is not just a biological matter
-ability to have certain continuous mental states- a prevailing consciousness, memories, a narrative of self and identity, desires for the future, rational thoughts etc
-if continuous mental states are no longer possible personhood can be lost
Limitations personhood (or sapience)
This is a very high bar for achieving moral concern- most childhood development experts think personhood isn’t developed until around 2
On the other hand some other mammals display at least some signs of personhood- elephants remember events and individuals for prolonged periods of time and mourn death
Personhood is also difficult to evaluate especially in those with communication difficulties
The philosopher peter singer argued that there is no quality that makes humans uniquely deserving of moral concern distinct from animals
-any quality you might identify to distinguish them will not be held by all humans (marginal cases)
-any quality that does cover all humans will also cover some animals
Personhood anthropologists
Anthropologists have pointed out that in societies where animals were not domesticated (farmed for meat or milk), animals are almost invariably considered to have spiritual worth, personalities and even intellect
Some have proposed that the denial of personhood to animals may be strategy to lessen the cognitive dissonance from the fact we are keeping them in conditions they would not choose and exploiting them
There are parallels with historical oppression of groups of humans who have been termed lesser in order to justify their control and exploitation
Potentiality
A being can be worthy of moral concern even if it has no qualities that would make it worthy of concern at the moment- if it might achieve those qualities in the future
Eg not currently sentient but might become so, does not currently have personhood but might
This has some attractions eg young children would have the same quotient of moral concern as everyone else
Potentiality limitations
But what about those who can expect no improvement in their condition does that mean we should be less concerned about them
What about those whose prognosis is to deteriorate
What role does the probability of attaining this status have in this approach
Almost everything would have some potential given long enough a lump of carbon could be sentient
Patient
A specifically medical model
-all patients are of moral concern to clinicians
-the status of patient grants full moral concern
-this is the basis of our professionals duties and obligations
Limitations patient
We cannot really believe that only people who are directly under our care are worthy of moral concern, so this is really a means of defining the scope of our professional responsibility rather than answering the question
At first glance offers little insight into cases where medics withdraw or withhold care
Where does that leave us moral concern
Moral concern is not something that has to be digital- its not the case that we either have concern or we dont
The most effective way of looking at moral status is to consider the various claims an individual has to our concern
Eg we might have some moral concern for being with only potentiality as a claim on our concern but not as much as we might for a being with full sentience and personhood
The loss of personhood is an area of particular relevance for doctors
Utilitarian approach
Would consider how to avoid the most possible suffering
How many dependents they have who’s loss leads to the most suffering
Deontologists
Duty to save life equal duty to both
However if you’re a follower of Kant you might believe that your duty depends on whether they have a good will
Rawlsian fairness
How old are you, what disadvantages have you had in life
Rawlsian fairness involves the equal distribution of privileges and burdens. A Rawlsian approach believes that inequalities should be rectified in the interests of fairness
Life buoy is a major privilege so want to give to person who so far had the least advantages in life. Might be in terms of their social status but also the years of life they have had the opportunity to experience
Care ethics life buoy
Can you swim
Care ethics orients around need- who needs this life buoy the most, in a storm swimming might not be such a advantage but can argue a non swimmer needs ring more
Life buoy clinician
Do you have any preexsiting health conditions
Clinicians in a context of limited resource tend to put those resources where they can do the most good
A clinician would probably want to save the individual with the best odds of long term survival or at least a high quality of life
Concepts of death
For the purposes of medicine death occurs when cardio-pulmonary arrest is irreversible
A legally accepted definition is given by the academy of royal colleges:
-the irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe… and therefore irreversible cessation of the integrative function of the brainstem
In most cases death is clear cut. However there are some grey areas/important concepts to define:
-brain stem death
-permanent vegetative states
-minimally conscious states
Brain stem death
Academy of medical royal colleges working party: the irreversible loss of the capacity for gaining consciousness and the capacity to spontaneously breathe
Following a brain injury leading to brain stem death, brain stem functions will not spontaneously occur unless supported by artificial means (eg mechanical ventilation), including;
-breathing
-temperature control
-brain function
-fluid balance
The heart will keep beating for a time after but eventually will cease due to increasing physiologic derangement even with ventilation
This is biological death legally even though the heart can continue beating for some time. Time of death is recorded as the time of conformation of brain stem death
Organ donation is possible after brain stem death
The legal status of brain stem death was challenged in 2015
The judge in the case confirmed the status of brain stem death as legal death
“Brainstem death does not equate to the death of the whole brain. There are studies that demonstrate that you can have electrical activity in some areas of the brain after brainstem death is established the key point is that not patient has ever regained consciousness or awareness”
Permanent vegetative state
Brian stem remains functional but mid brain and cortex are non functional
Loss of all higher mental functions but basic biological functions remain
“A clinical condition of wakefulness without awareness”
Only reflexive motor activity, no purposeful response to stimuli
If this lasts more than 4 weeks it is termed ‘continuous vegetative state’ if it lasts more than 6 months (from a non traumatic cause) or more than 12 months (from a traumatic cause) it is termed a permanent vegetative state
Chance of recovery after this timeframe is almost zero- although there are isolated cases of partial recovery
This is biological death- death of personhood there is no possibility of continuous mental states/consciousness
Once the diagnosis is established withdrawal of nutritional support is often considered
Minimally conscious states
A condition of severely altered consciousness in which minimal but definite behavioural evidence of self or environmental awareness is demonstrated
More continuous improvement and significantly more favourable outcomes post injury when compared with vegetative state
NHS principles
Free at the point of delivery
Comprehensive service available to all
Funded mainly through taxation
NHS patient pathway
Social care—> patient<— social determinants of health
—> clinician (provider: hospital/GP)
Doctor patient not a usual exchange relationship compared to buying food or shoes etc
NHS in England flow of money (mainly public, some private)
Public/patients—> taxation—> government
Public—insurance premiums—> 3rd parties: CCGs (ICSs) and insurance
Government—resource allocation—> 3rd parties: CCGs and insurance
3rd parties—funding—>providers—services—> public/patients
NHS England flow of money
Government/ dept of health and social care
-integrated care systems board
—NHS trust 1
—NHS trust 2
—independent hospital
Primary care different funding flow
General tax England
High equity progressive tax
Low transparency
Low choice
Macro efficiency: global; budget, cost control
Micro efficiency: low running costs
Social insurance Germany
Equity medium/high, near universal
Medium transparency, hypothecation
Medium choice: choice between providers, not insurers
Macro efficiency: demand led or global budgets
Micro efficiency: high running costs. Tax on work?
Market America
Weak equity, risk based
High transparency: payment and benefit linked
High choice
Macro efficiency: demand led, poor cost control
Micro efficiency: high running costs, tax on work?
Should patients be charged to see GP
Patients in most need are least able to pay. Key plank of NHS= universal health care
Affluent patients may demand more (time/visits)- charge/fee makes healthcare a commodity
Deters patients from seeing GP- late presentation, higher costs
Admin costs of charging scheme: ironic as common complaint of NHS, chasing defaulters
Charging £20 per visit only makes 4.8% NHS budget not helpful
Major impact on health inequalities. NHS-social solidarity of universal service
Is the NHS being privatised
Some aspects of NHS care involve the “private” sector GPs=independent contractors
Pharmaceuticals
NHS pay beds and private/independent sector treating NHS patients
Debate about what privatisation means no consensus
Privatisation debate linked to NHS internal market/commissioning, intrusion of private capital
Eg:
-mental health services
-private finance initiative PFI
-commercial income
Can the NHS survive this 2023-24 crisis
NHS has been called a “burning platform” Richard’s 2017
NHS model might still be relevant- free at delivery, tax funded but organisation of care needs updating
Hence new models of care are required kings fund etc:
-better use of IT (digital first primary care)
-virtual wards/hospital at home
-better health and social care integration: risk stratification
External and internal challenges
External challenges
Need more attention to improving population health
-health care accounts contributes 15-20% to health
-poor population health ~ poor outcomes from NHS care
Internal challenges
Workforce:
Strong research evidence about the human resource management and patient outcomes:
-appraisal systems= strongest association with lower patient mortality
-higher % of staff working in teams within a hospital the lower the patient mortality
Strategies: WHO 2006
-respond to need
-prepare the workforce
-making the most of existing workers
-managing exits from the workforce
ABC: autonomy, belonging, control
Why are there too many mangers
NHS management only introduced in the 1980s
NHS is complex, high risk organsiation
NHS has low admin costs by international comparisons
Paradox calls for better management to behave more like private sector, yet salaries and staffing not equivalent
Key trend: clinical staff take on managerial roles:
-eg medical director, clinical director, clinical services manager etc
-evidence: hospitals with medical CEOs perform better
-leadership no longer seen as betrayal of medicine, faculty of medical leadership and management
NHS could be considered under managed
We already spend too much on NHS
Criticism: NHS is a “bottomless pit”
UK spend 12% of national income on health
NHS spending reliant on economy
Surprising if NHS spending had not increased due to inflation, population growth and COVID
Governments have increased NHS budget but not enough
4% health care inflation ~2% ageing population; 2% technology
Is more NHS spending the answer
Three policy solutions:
-increase taxes to maintain level of spending needed to keep current level of NHS care
-reduce spending on other services such as education and welfare to maintain level of spending needed to keep current levels of NHS care
-reduce level of care and services provided by NHS
