Health Challenges: Western Paradigm Challenged

[Abu-Salman]

1- "Medicalisation" Excesses: Psychiatry's Problematic Boundaries or How To "Pathologise" Normal Behavior.

 

 

And even in affluent societies anyone who has a child with schizophrenia or a severely depressed husband knows all too well that our current treatments and services are inadequate. It is now over half a century since the last genuine breakthrough, the discovery of chlorpromazine. Like it or not, the next major leap forward in the treatment of major mental disorders will come from neuroscience, and will be funded by the pharmaceutical industry. Pathologising shyness, eccentricity, or sadness does few any favours—neither those who receive unhelpful labels, nor those with major mental disorders who need all the resources and research we can muster. (The Lancet, March 2008)

 

 

2- Bioethics beyond the lifespan, Larry R Churchill (The lancet, March 2008)

 

What are our responsibilities for a future we will not live to experience? How should we think, morally speaking, about a world that will not include us? Environmentalists are now asking these questions with regularity. They demand that we think about the severity and frequency of storms and droughts predicted to occur in the second half of the 21st century and consider which low-lying land masses will be under water if the polar ice caps completely melt—events that may occur after many of the readers of this essay are dead. Certainly many parents and grandparents think locally, if not globally, about their own demise, especially in terms of the material goods and spiritual legacy they should bequeath to their progeny.

 

In the field of bioethics, however, thinking beyond the individual lifespan has been largely absent. The mapping of the human genome and the advent of gene transfer research has spawned a concern for possible hazards to future generations from new pathogens and germline alterations, but a focus beyond the lifespan has clearly not penetrated to that part of bioethics concerned with more routine medical practices and policies. The stories that preoccupy bioethicists about rights, duties, and responsibilities seldom move beyond scenarios of the dramatic choices of individuals and their families, frequently focused as end-of-life conundrums taking place over a time frame of days, weeks, or months. It is rare to find bioethical frameworks that extend beyond the lives of the patients, and even the health-care professionals and families who are typically engaged in deciding how much is too much and who gets to decide.

 

The case of Terri Schiavo, the Florida woman who was in a persistent vegetative state for more than 15 years, is a good example. The very public legal, ethical, and policy debates that surrounded her death never ventured far from the proximate issues of diagnostic accuracy, feeding tubes, and decisional prerogatives. When extended time frames were evoked, they addressed past actions, for example: Had Mr Schiavo's call for emergency medical services during his wife's original cardiac arrest been quick enough? Was the testimony of witnesses about Ms Schiavo's previous wishes for care reliable? Whether the issues were couched as “right to life” or “patient autonomy” the single lifespan was presupposed as the relevant frame of reference. I am not suggesting that long-range policy implications should have dominated the decision process, but it is incumbent upon us to raise those issues now. Bioethics without a beyond-the-life-span perspective is increasingly problematic as current medical policies leave a larger and larger social footprint. Then Florida Governor Jeb Bush called a special session of the state legislature to keep Ms Schiavo's feeding tube in place, in the same legislative year in which thousands of poor children were removed from the Medicaid rolls. These children, thus barred from access to health care, will reap the consequences long after all the parties to the Schiavo dispute and the Florida legislature are gone.

 

Beyond its obvious health myopia, a bioethics that fails to appreciate the interlocking of present medical priorities and future health possibilities is also impoverished through its neglect of some central human virtues. Perhaps the chief of these neglected virtues is altruism. Coined by the French social theorist Auguste Comte, “altruism” is generally understood to mean selfless concern for others (from the Latin alter, “other”). Of course placing the interests of others above one's own can be done with an exclusive view to the present, without any regard for a future that does not include the agent. But this limited notion of altruism seems to sap its essential meaning. Perhaps sociobiologist Edward O Wilson was on the right track when he described altruism as “generosity without hope of reciprocation”. Only after death is this hope extinguished and not a potential factor in our motives. We need not agree with Wilson about the source of this fundamental virtue to appreciate his argument that the persistence of altruism in the human species suggests it has an important survival value for us.

 

To be sure, altruism is evident in medicine in a variety of ways that are not sufficiently appreciated by the dominant strands of bioethics. For example, the traditional ethics of medicine enjoins physicians to place their patients' good above their own self-interest. Edmund Pellegrino and David Thomasma, in The Virtues in Medical Practice, call this “self-effacement”—a felicitous phrase that highlights the suppression of narcissism in attitudes and actions focused on other people. Physicians who deprive themselves of sleep or income to attend to their patients' needs know intimately the meaning of this virtue. Yet admirable as it is, self-effacing altruism may lack the special feature of beyond-the-lifespan responsibility that concerns me in this essay. A closer approximation may be found in the attitudes of severely ill research participants in early-phase clinical trials, who often talk about their interest in finding remedies for future patients. The distinguishing feature here is the desire for a good that one will not live to see, eliminating the possibility of gratitude from future beneficiaries.

 

Bioethics was initially concerned with decisions about the medical care of individuals, both in terms of their inherent moral qualities and in terms of whose voice would be privileged in these decisions. As the field matured, there was a gradual broadening to considerations of social justice in health policies. Norman Daniels and Daniel Callahan are among the most important contributors in the movement towards the social justice dimensions of bioethics, introducing diachronic—or “through time”—notions such as fairness across the lifespan, and the prudent use of limited health-care resources. But the implications of lifespan scarcity are often framed as intergenerational conflict, for example, how many medical resources should be allocated to the elderly as opposed to children? Rarely does lifespan thinking flower into beyond-the-lifespan thinking, in which individuals and groups are encouraged to think about their responsibilities to a future that will not include them. If as an elder I forgo solid organ transplantation so that children will receive inoculations or expectant mothers receive prenatal care, this is surely admirable but still largely a calculation based on a synchronic exchange, a present time trade off. Environmental advocates ask us to be accountable for our present carbon footprint in order to prevent the Netherlands from becoming part of the North Sea in the late 21st century. There is no robust equivalent in bioethics.

 

Perhaps one of the barriers to a beyond-the-lifespan perspective in bioethics is that there are so few ethical theories or moral traditions that explicitly recognise it. For example, John Stuart Mill does not seem mindful of future generations when he advocates the greatest good for the greatest number. Nor is Immanuel Kant eloquent on beneficent duties to a world one will not live to enjoy. Hans Jonas is among the very few who have made responsibility for future generations a priority in his ethical theorising; he rewrote Kant's categorical imperative to read, “Act so that the effects of your action are compatible with the permanence of genuine human life…or are not destructive to the future possibility of such life”.

 

Religious traditions may have more to teach us, especially through the recent emergence of religious environmentalism. One powerful theme of religious environmentalism is the idea that the earth is not our possession, but that we are caretakers of it, so that a major benchmark of ethics is stewardship of resources that are essentially given in trust, to be passed on to future generations. Thus, caring for a future beyond our lifespan is a way of living responsibly in the present. What would it mean to have such a moral standard in bioethics, that is, to ask about the impact of our post-mortem health and medical footprint? Returning to the Schiavo case discussed earlier, a beyond-the-lifespan approach in bioethics would mean policies that actively discourage the use of feeding tubes for patients disabled by their conditions.

 

More broadly, a beyond-the-lifespan dimension to bioethics would also mean far less attention to medicine and far more to public health. If personal medical care accounts for only 10% of health status, and social circumstances, environmental factors, and health behaviours are far more important, then bioethics should shift its focus away from personal medical services and towards the creation of sustainable health policies. Bioethicists would then ask hard questions about the wisdom of the ever-expanding and very expensive medical systems that dominate the public budgets of most industrial democracies. Can these megatechnologies be passed on to future generations, or will they further exacerbate health disparities? What Emily Friedman has termed an “epidemic of medical indigence” is perhaps the most powerful and far-reaching legacy of current health policies, both in the USA and globally.

The legacy of bioethics beyond the lifespan lies in the realisation, or the failure to realise, that health is not just about the current wellbeing of individual organisms, but population (species) survival.

 

3- Single Most Crucial Health Challenge Unadressed: Water & Sanitation