Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of (...) a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS l. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[1] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[2] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. ll. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[3] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[4] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[5] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[6] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[7] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[8] In democratic societies, one must take into consideration community morals and values.[9] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[10] lll. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[11] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[12] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[13] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[14] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. lV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[15] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[16] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[17] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[18] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[19] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[20] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[21] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. Vl. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[22] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[23] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[24] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. Vll. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [1] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [2] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [3] Moss, p. 1295-1298. [4] Moss, p. 1296. [5] Moss, p. 1295-1298. [6] Moss, p. 1295-1298. [7] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [8] Cohen, p. 1299-1301. [9] Moss, p. 1297. [10] Cohen, p. 1300. [11] Cappelen, p. 478-480. [12] Cappalen, p. 478-480. [13] Cappelen, p.479. [14] Cappelen, p. 479. [15] Cappelen, p. 479 [16] Cohen, p. 1301. [17] Cappelen, p. 478. [18] Cohen, p. 1299-1301. [19] Cohen, p. 1301. [20] Cappelen, p. 476-480. [21] Cappelen, p. 476-480. [22] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [23] Kawachi, p. 18-33. [24] Kawachi, p. 18-33. (shrink)

What are we to make of the claim that we often hear, that there is no such thing as business ethics? This essay first examines two arguments that might be in people's minds in making such a claim — that business is a game, and hence the ordinary constraints of morality do not apply, and that one cannot survive in business if one is too ethical. The critique of these arguments begins the process of making clear what business ethics is. (...) The paper then proceeds in a more positive vein to define and explain for the sceptic what business ethics is. Everyone must confront the question, what should I do in my business relationships? Business ethics is defined, then, as the effort to develop Socratically one's answer to this question, that is, through the critical examination of alternatives. In the process of explaining this notion, several other senses in which someone might say that there is no such thing as business ethics are explored and the basic distinction between the moral point of view and ethical egoism is introduced. (shrink)

In arecent article, Michael Murray critiques several versions of universalism-that is, the doctrine that in the end all persons are saved. Of particular interest to Murray is Thomas Talbott’s version of universalism (called SU1 by Murray), which puts forward a strategy for ensuring universal salvation that purports to preserve the autonomy of the creatures saved. Murray argues that, on the contrary, the approach put forward in SU1 is not autonomy-preserving at all. I argue that this approach preserves the autonomy of (...) the creature at least as well as the approach posited by the traditional doctrine of hell. Since SU1 clearly does more to preserve the well-being of the creature, it follows that, on the assumption that God loves all His creatures, SU1 is preferable to the doctrine of hell. (shrink)

The normative dimension of language and thought has been cited recently in arguments against naturalist reductions of the intentional--of meaning, belief, and desire. These arguments have been met with much scepticism, primarily because their proponents say little about the kind of 'normativity' on which they depend. There is, however, a rich tradition in ethics of thinking about the nature of the normative, and why it might pose a problem for naturalist reduction. ;In this dissertation, I bring the discussions in language (...) and ethics together, arguing that doing so lends clarity and plausibility to the objections to naturalist reduction in both fields. In Part I, I draw from ethics to characterize normativity, and to explain how it provides a barrier to naturalistic reduction. In doing so, I respond to two common criticisms of irreducibility arguments in ethics: that they only show the irreducibility of our concepts of the ethical, not of ethical properties; and that they depend on outdated views of conceptual analysis. I argue that both objections misfire, though for interesting reasons, and that the anti-reduction argument succeeds. ;In Part II I use the characterization of normativity to shed light on recent arguments against reducing the intentional. I examine two prominent authors who have advanced such arguments, Saul Kripke and Donald Davidson. In addition to fleshing out and defending each of their arguments, I develop a general challenge to any reductive approach. The proposal is that intentional items have an essential capacity to define a context of reasons, something to which no naturalist reduction can do justice. ;In Part III I consider a new trend toward non-reductive forms of naturalism. I argue that most current non-reductive accounts also fail to accommodate the requisite normativity. But if the non-reductive, naturalist approach is developed in a certain direction, one which depends on the idea of response-dependency, it can capture just the kind of normativity that is needed. In closing, I briefly defend such an approach to both intentionality and value. (shrink)

In my field, animal developmental biology, and in what could be regarded as its “deep time derivative,” the evolutionary biology of the animal body plan, there exist two kinds of experimentally supported causal explanation. These can be described as “rooted” and “unrooted.” Rooted causal explanation provides logical links to and from the genomic regulatory code, extending right into the genomic sequences that control regulatory gene expression. The genomic regulatory code ultimately determines the developmental process in a direct way, since subsequent (...) developmental events all depend directly and specifically on what regulatory genes are being expressed and where in the developing organism they are being expressed.. (shrink)

There has recently been a revival of interest in ‘naturalizing’ ethics. A naturalization seeks to vindicate ethical realism — the idea that ethical judgments can be true reflections of a moral reality — without violating the naturalist constraint that science sets the limits of ontology. The recent revival has been prompted by examples of successful scientific reduction (e.g. temperature, water), and by the emergence of new, nonreductive naturalist strategies (e.g. for biological and mental properties). In this paper, I argue against (...) such naturalist approaches to ethics. My argument builds on the traditional one offered by G.E. Moore, namely that a naturalization would fail to respect an existing difference between the meanings of moral and naturalistic terms. I defend this line of argument against the common claim that it cannot block ‘synthetic’ property identities, ones grounded not in meaning equivalences but in empirical discoveries (as in the cases of temperature and water). I then go on to show that the Moorean argument can make trouble even for recent revisionist and nonreductive naturalist approaches. (shrink)

Both Arne Naess and Warwick Fox have argued that deep ecology, in terms of “Selfrealization,” is essentially nonmoral. I argue that the attainment of the ecological Self does not render morality in the richest sense “superfluous,” as Fox suggests. To the contrary, the achievement of the ecological Self is a precondition for being a truly moral person, both from the perspective of a robust Kantian moral frameworkand from the perspective of Aristotelian virtue ethics. The opposition between selfregard and morality is (...) a false one. The two are the same. The ecological philosophy of Naess and Fox is an environmental ethic in the grand tradition of moral philosophy. (shrink)

The successes of molecular developmental biology over the last ten years have been particularly impressive in those directions favored by its major paradigms. New technologies have both guided and been guided by the progress of the field. I review briefly some of the major insights into embryonic development that have derived from research in four specific areas: early embryogenesis of various forms; “pattern formation”; evolutionary conservation of regulatory elements; and spatial mechanisms of gene regulation. There remain many major problem areas, (...) some of which may require new orientations to solve. (shrink)

The Material Culture of the Northern Sea Peoples in Israel. By Ephraim Stern. Harvard Semitic Museum Publications, Studies in the Archaeology and History of the Levant, vol. 5. Winona Lake, Ind.: Eisenbrauns, 2013. Pp. ix + 74, illus. $29.50.

Developmental processes in complex animals are directed by a hardwired genomic regulatory code, the ultimate function of which is to set up a progression of transcriptional regulatory states in space and time. The code specifies the gene regulatory networks (GRNs) that underlie all major developmental events. Models of GRNs are required for analysis, for experimental manipulation and, most fundamentally, for comprehension of how GRNs work. To model GRNs requires knowledge of both their overall structure, which depends upon linkage amongst regulatory (...) genes, and the modular building blocks of which GRNs are heirarchically constructed. The building blocks consist of basic transcriptional control processes executed by one or a few functionally linked genes. We show how the functions of several such building blocks can be considered in mathematical terms, and discuss resolution of GRNs by both “top down” and “bottom up” approaches. BioEssays 24:1118–1129, 2002. © 2002 Wiley‐Periodicals, Inc. (shrink)

In response to powerful criticisms of older arguments, contemporary defenders of the Church’s traditional stance on homosexuality have fashioned a new kind of argument based upon the special relationship God created between the sexes. In this paper we examine two recent incarnations of this kind of argument and show that both fail to demonstrate the inherent immorality of homosexual relationships, and at most demonstrate that homosexual relationships are inferior to heterosexual relationships in certain respects. At the end of the paper (...) we argue that a good God would have reason to make a certain proportion of humanity homosexual in order to unmask sexist myths. In this way homosexuality could itself strengthen, rather than weaken, the special relationship God created between the sexes. (shrink)

In short, the anticipated harm (death) to Ms. A of telling her about her child greatly outweighs the harm she will experience by being lied to. Also, the latter harm can be ameliorated; the former can not.

In the maximal form of indirect development found in many taxa of marine invertebrates, embryonic cell lineages of fixed fate and limited division capacity give rise to the larval structures. The adult arises from set‐aside cells in the larva that are held out from the early embryonic specification processes, and that retain extensive proliferative capacity. We review the locations and fates of set‐aside cells in two protostomes, a lophophorate and a deuterostome. The distinct adult body plans of many phyla develop (...) from homologous set‐aside cells within homologous larvae. We argue that the stocks from which these phyla arose utilized these respective larvae, and the diversity of their adult body plans reflects diverse pattern formation processes executed in their set‐aside cell populations. Chordates and arthropods develop directly, but share adult characters with indirectly developing phyla. Thus the deuterostome and protostome stocks that were ancestral to chordates and arthropods, respectively, also utilized maximal indirect development. (shrink)

One of Gottlob Frege’s most original contributions to logic and philosophy was his logical notation, his ‘Begriffsschrift’. While long criticized, dismissed, or simply ignored, the recent secondary literature contains some helpful re-evaluations and partial defenses of it. These rely largely on technical, pragmatic, or cognitive-psychological considerations. In this paper, we reconsider Frege’s own reasons for valuing his notation highly. We argue that there is a further semiotic dimension, one that matters epistemologically. This dimension becomes evident once one takes seriously, partly (...) also literally, some striking visual metaphors Frege uses. The result is an interpretation highlighting a side of Frege’s position that is not widely known. It involves his views about the indispensable role that language, or sign systems more generally, play for human thought, and especially, for logic and mathematics. More particularly and as we read Frege, a good logical notation allows for expressing conceptual/inferential relations in a ‘visually inscribed’, thus ‘perspicuous’ way, and this leads to a special kind of ‘insight’ in mathematics. Or as we elaborate this point further, it involves a kind of articulation and understanding hardly possible without it. Frege designed his Begriffsschrift with that specific goal in mind. (shrink)

What are the processes, from conception to adulthood, that enable a single cell to grow into a sentient adult? Neuroconstructivism is a pioneering 2 volume work that sets out a whole new framework for considering the complex topic of development, integrating data from cognitive studies, computational work, and neuroimaging.

Written in debate format, this book covers developing fields such as social cognition, as well as classic areas such as memory, learning, perception and categorization. The links between emotion and memory, learning, perception, categorization, social judgements, and behavior are addressed.

There is an increasing interest in how to organize operations carried out by multiteam systems. Large MTS typically operate with a dedicated integration team, responsible for coordinating the operation. We report a study of a military multiteam system that prosecute time-sensitive targets. We asked whether and how the integration team’s efficiency depends on its communication setting. Specifically, we studied how a co-located vs. a distributed communications setting influenced the shared situation awareness and whether the shared situation awareness again influenced the (...) outcome of the decision processes. We found that performance fell when the integration team shifted from a co-located to a distributed setting. The fall in performance seemed to be mediated by a corresponding fall in situation awareness. Moreover, while the performance improved for each run in the co-located setting, we did not see such learning in the distributed setting. Qualitative observations revealed that misunderstandings lasted longer in a distributed configuration than in a co-located setting. We found that situation awareness at level 3 was the only level of situation awareness significant for predicting all dimensions of performance. Implications for theory, research, and practice are discussed. (shrink)

Book reviewed in this article: Suffering and the Beneficent Community: Beyond Libertarianism. By Erich H. Loewy. The Nature of Suffering and the Goals of Medicine. By Eric J. Cassell.