Defending Beliefs: Objectivity as Validation for Critiques of Health Care Resource Allocation

Thomas Ehrich
Gustavus Adolphus College
April, 1996

I will give no deadly medicine to any one if asked, nor suggest any such counsel. -- Oath of Hippocrates
He thinks that the physician's knowledge of illness extends beyond the nature of health and disease. But in fact the physician knows more than this. Do you imagine, Laches, that he knows whether health or illness is the more terrible to a man? Had not many a man never get up from the sickbed? I should like to know whether you think that life is always better than death. May not death often be the better of the two? -- Plato
The term "objectivity" is commonly applied to epistemic theories of knowledge. Questions using the term include, "Is this scientific theory objective?" or, "Are you objectively sure about what you saw?" However, the term "objective" also has application in the endeavor of inquiry. One can be said to be "objective" about the way in which knowledge is gained, not just the knowledge itself The exact definition of what counts as "objectivity" in the process of gaining knowledge, is, of course, a matter of some debate. Nonetheless, under this broad heading, a system of inquiry can be said to be objective in some narrower sense. A critique can be seen as an inquiry, for a critique demands an understanding of the object of the critique, and any suggestions which arise from the critique are themselves inquiries into possible ideas. Thus the language of objectivity can be used to examine and assess the validity of a critique. This way of examining a criticism or suggestion is useful because is allows us to examine under what criteria a critique or suggestion is to be counted as valid.

In order to do this, however, we must examine what counts as objectivity. Objectivity is commonly taken to mean, "freedom from idiosyncrasies." An idea is objective to the extent that it is unpolluted by the individual's beliefs or presuppositions; a critique is objective to the extent that the person making the criticisms and suggestions ignores their own personal feelings an biases. Objectivity in this sense is often defined as the negative of personal subjectivity, or as the opposite of personal opinion.

A corollary of this definition of objectivity in ethics extends to such classically liberal values as justice and fairness, because these do not rely on personal feelings; they can be worked out almost as a mathematical problem such as "person A will receive this much good from this action, while group B will receive this much." Both Kantian and utilitarian ethics work well within the language of objectivity because they offer sweeping absolutes which do not take into account individual opinions or beliefs. Also, viewing everyone as fundamentally equal in terms of their needs allows the theorist to ignore concrete situations.

Examples of this definition being used as a criterion for the validity of a critique abound. A radical feminist suggestion for the improvement of human reproduction, which holds that we ought to develop and use technology to end biological pregnancy or to share it between the sexes, can be seen as objective in the sense that women endure the discomfort and pain of pregnancy needlessly and thus any impartial solution would have to involve either the sharing of pregnancy between sexes or the abolishment of biological pregnancy altogether. The suggestion itself can be seen as based on an inquiry into the experience of pregnancy. One half of the world's population experiencing pain when theother half doesn't have to is objectively wrong under both a utilitarian and a Kantian calculus. The language of objectivity can be used to "critique the critique," assessing how well it fits in with our culturally dominant social/ political views. I believe that the reasons for this are tied in with the advent of science as the dominant Western paradigm. Science uses the language of objectivity (in this case empirical objectivity) to justify itself, and many other areas of human endeavor, including rhetoric, have followed suit. An example of this is health care. With many different competing critiques and suggestions for reform, objectivity offers a language of assessment; it offers a way of evaluating the validity of a critique. However, I propose that neither definition of objectivity works well when examining critiques and suggestions dealing with health care, and that for this issue another definition of objectivity is needed, rather than another application of the old definition.

The system of health care in America has recently been a matter of heated debate. Although our medical technology is second to none, and although much of the health care system is staffed by genuinely caring individuals, there are very deep problems which need to be addressed. As a report from the Urban Institute of Washington, DC, states, these problems are "cost and access." As can be seen from the statistics sheet, the costs of health care in America is staggering, and is only going to increase under the current system. Yet in spite of this vast outpouring of resources, a disturbing number of Americans remain without any health insurance whatsoever. As these families and individuals are most often the very poor, this means that they have no access to health care at all.

Much of the current difficulty with health care derives from the allocation of resources. Health care continues to utilize more and more of our nation's resources, creating more and more of a burden. As a nation our resources are not infinite. Energy, material, and human expertise that goes toward health care cannot go toward other areas. Thus other important areas of concern such as education and the environment could conceivably suffer due to an uncontrolled increase in health care expenditures. Issues in health care availability can also be seen in this light. Were health care itself more affordable, then perhaps the poor would have greater access to it. Thus the twin problems of cost and availability can be perceived as the same, and a solution to one will not occur without a solution for the other.

I propose not a solution for this problem directly, but rather a new way of making inquiries into the nature of this dilemma. In order to assess this, it is helpful to examine our current methods of inquiring into health care resource allocation, as these methods will inform our criticisms and suggestions. From there we can determine which, if any fall the above definition of objectivity, and whether or not a different definition of objectivity would be more appropriate.

This is complicated because Americans currently rely on a mixture of government and private funds to pay for health care -- there is no singly underlying paradigm which governs all our collective actions on health care distribution. Medicare and Medicaid are both government programs designed to pay the health-care services provided for the elderly and the poor, respectively. At the same time, many (but by no means all) workers rely on their employers to provide them with health insurance. Still others purchase health insurance on a individual or family basis.

The preponderance of private insurers can be seen a manifestation of our fundamentally capitalist society. The quality of health care coverage is based, as are so many other things, on the amount that the buyer is willing to pay: caveat emptor. At the same time, we are not willing to say caveat senex,1 and therefore spend a sizable portion of our annual gross national product on the physical care of the elderly (please see the sheet for exact numbers). Likewise we feet the collective need to pay for the health care services provided for the poor. In short, our system indicates that we generally feel that health care, like any other service, ought to be essentially a market endeavor, so long as those who could normally not participate are still able to receive care. Unfortunately, rising costs and lack of coverage mean that our cur-rent quasi-capitalist system falls on both counts.

It should not be surprising, however, that many of the criticisms and suggestions dealing with health care resource allocation have their roots in either the capitalist or the socialist side of this argument. Some claim that as a nation we ought to look to Canada or Britain for guidance, systems which are more socialist than we in their socioeconomic philosophies. Others argue that we should look to the market as a solution, and that our current problems stem from socialist incursions into what ought to be a private enterprise. Both systems of inquiry operate under the above definition of objectivity.

Capitalist suggestions for the reform of the health care system include replacing current socialist programs, such as Medicare, with more private enterprises, such as HMO'S. The capitalist critique of health care provision has as its assumption that resources are currently being utilized unwisely. Remembering that current problems can be conceptualized as problems of cost and of availability, we can see that the capitalist focuses on cost. As the Urban Institute notes, "the rationale for competitive reforms... has been to improve efficiency" (Arnould, et al, p.12). The capitalist begins their inquiry by asking, "Where is money being wasted?" The inquiry focuses on numbers in terms of dollars spent and is objective in the sense that it looks at economics rather than emotions. Capitalists then proceed with the assumption that the market will lower costs due to the nature of free enterprise and competition. Economic forces will then ensure that costs will fall in the future.

The capitalist suggestions are objective in the sense that they are, like the system of inquiry, examining primarily numbers rather than people. Personal idiosyncrasy cannot have any bearing when human beings as individuals do not even enter into the calculations, either of the current system or of proposed changes. Thus this critique falls well under the definition of objectivity as impartiality. Unfortunately, it also fails because proposals for the further privatization of medicine in America rarely take into account the millions who are already without coverage. Viewing everyone as objectively equal would mean that this solution is not objective because it favors the wealthy. Of course, someone touting the benefits of market reform will not agree with this point, but one major idea of capitalism is that quality of service is inherently related to the amount of money spent on that service.

The socialist critique also focuses on numbers, but here the numbers represent the people who do or do not have access tc health care. As mentioned earlier, this critique often uses other nations, such as Canada ) or Britain, as models for what America should be doing. It too falls squarely under the definition of objectivity as impartiality. Depending on which sides of the "socialist solution" are being touted, socialist critiques address cost containment, availability, or both. Socialism-based suggestions for the reform of medicine view all Americans as being equally permitted health care of equal quality. Again, individual idiosyncrasies can have no be ring, as all are assumed to be entitled to equal health care, and none would be favored. Although socialist in an economic sense, an analysis of the critique shows it to be classically liberal in the political sense because it assumes an equality of needs.

Retaining the language of using objectivity as a criterion for validation, the socialist model fails under the sense of objectivity as impartiality in that "the numbers don't add up:" the socialist critique would cause greater misery in the form of exponentially rising taxes than it would alleviate. As an example of this, consider Britain, which is struggling with its own form of socialized medicine: the Urban Institute notes that "[u]ltimately, the correct level of funding of the [British National Health Service] is a political question that hinges on the willingness of taxpayer-voters to devote more resources to health at the expense of higher taxation and/or lower spending on other public services" (Posnett, p.296). A fully socialist model in which all Americans were entitled to full health care would be economically unsustainable given our demographics. Please see the statistics sheet for information on the cost of health care to the government under the current system, as well as the prospects for growth of expenses in the future.

The capitalist and the socialist models are both grounded in objectivity in the sense that they are primarily interested in impersonal, sweeping changes, often the result of government action, that are motivated by an analysis of numbers rather than of humans as emotional beings. Change takes place at the institutional rather than the personal level. This means that some aspects of health care are not even examined. For example, exactly what amount of health care ought to be given to whom is not commonly debated, as an objective paradigm assumes that everyone ought to he entitled an equal amount of care.

One aspect of this are the related areas of euthanasia and Do-Not-Resuscitate orders (commonly known as "living wills"). The sacred quality of human life is so deeply ingrained into the Western medical psyche as to be virtually unquestionable: the Hippocratic Oath expressly forbids physicians from knowingly administering any drug which will cause death under any circumstances. This simply goes against common sense: like Plato's Laches, our society seems to think that the physician's knowledge extends to concerns of life itself, beyond questions of health and disease. Today our physicians seem to believe that they have greater knowledge of whether "a man ought to get up from the sickbe4f' than the person in the sickbed. The American Medical Association condemns euthanasia in strong terms, This attitude has led to cases where patients are kept alive contrary to their wishes, even though they are in considerable pain and are using considerable resources. Human life is valued above human life. This is not merely a problem of physicians, for we are collectively responsible as members of this society to see to it that physicians are trained ethically within our own cultural norms. Somehow, this has not happened, as physicians have assumed the mantle of God when deciding whether or not to keep patients alive. This attitude has its roots in our notion of objectivity, because avoiding personal idiosyncrasies means looking at lives as absolutes to be kept alive as long as possible rather than being sensitive to the context in which those lives are lived.

Another problem is that of long-term care. The elderly often give away their possessions to their children before they enter a nursing home, knowing that they could never afford to maintain themselves in a long-term care situation, but the state will. Looking at the sheet, we can see that long term care is already a very expensive part of our nation's health care system, and that it is only going to get worse. Capitalist and socialist models will debate ways to possibly make this care less expensive, but the whole concern of whether or not long-term care is itself morally right or economically sustainable seems beyond discussion.

The definition of objectivity, however, offers no way to deal with problems such as these, even when they relate to the use of resources. The issue of when one ought to die rather than live is simply too personal to figure into objective moral calculations -- one cannot make sweeping proclamations about when one no longer qualifies as fit to live due to illness. Objectively looking at all human life and needs as equal means that some aspects of long term care cannot even be discussed.

So far I have been speaking of medical resources chiefly in terms of monetary resources. However, modern medicine makes use of materials that would not have even been thought of as "resources" fifty years ago. Organ transplants, for instance, expand the category of "resources" to include a twin brother's kidney and a liver gleaned from a cadaver.

What are the guidelines under our current system? Surely questions as fundamental as who receives a fife-saving transplant and who doesn't is both too complicated and too emotional to be figured by some magical ethical formula. We seem to collectively recognize this, and have tentatively begun to auction off these responsibilities to "experts," in this case medical ethicists. This means that questions which have a great impact on loved ones who may or may not need transplants as well as all of us in terms of cost are being shunted off to a relatively small group of people. It seems very odd that we so eagerly shirk issues that affect all of us.

Because the language of objectivity in the classical sense does not seem to offer viable solutions to the problems of health care resource allocation, and because it completely fails to consider other aspects of health care even when they are related to resource allocation, I propose that we adopt a new standard of what counts as an "objective" inquiry into how money, material, or skills are used in health care.

Specifically, I wish to look at the definition of objectivity recently proposed by Drs. Lisa Heldke and Stephen Kellert: objectivity is characterized by responsibility. Responsibility in turn is characterized by responding: "To be responsible, in our sense, involves responding -- to a demand, a request, or a criticism, stated or implied"((Heldke and Kellert, p.6). Thus we are challenged to respond to a variety of sources when we determine the allocation of medical resources. It also means that we are responsible for our own decisions: "The second aspect of responsibility relevant for our definition of objectivity is accountability." -- p.8. We must take into consideration the wider effect of our inquiries and actions.

This definition avoids the conceptual trap of the other by refusing to yield to general calculations; rather it operates on a case-by-case basis. It can do this because the decision-making is an ongoing process whereas the former definition of objectivity offers a sweeping proclamation that can be applied to all instances. This does not mean that two or three people are going to have supreme authority in determining the use of medical resources for a given patient. This is a communal process, and communities at the local, regional, and national levels must engage in debate to set general guidelines.

Furthermore, the people utilizing the medical resources are accountable for their use. The issue of accountability means that the people making concrete decisions, such as patients, family members, physicians, and the public must consider the ramifications of their decision on society in general, rather than merely on their own insurance policy: "... the emphasis on responding draws our attention to the fact that inquirers respond to those in the wider community who are not directly involved in the inquiry process, but who nevertheless stand to be affected by its results or affected by its application." -- p.7 In the case of health care resource allocation, everyone stands to be affected and so ought to take an interest in the conversation.

Looking at objectivity as "accountable responding" also means that anything can be debated, and that possible solutions which elude us now because we won't talk about them can actually be discussed. Heldke and Kellert use John Stuart Mill's defense of free speech as an example of what they have in mind: "Mill, recall, defends free speech on the grounds that exposing one's ideas to the challenges of others enables one to strengthen and improve one's ideas." --p.19 The public dialogues about health care resource allocation would only benefit by opening more issues for debate.

One advantage that this way of examining critiques has over the old is that the context matters. Liberal objectivity does not take context into account, because that would mean inviting personal idiosyncrasies. Context ought to figure very prominently into the considerations of resource allocation, and this new way of objectively examining a critique demand that it does. A scenario would be helpful here: An person suffers a stroke and is left in a semi-vegetative state. This person retains some movement, but has lost the function of speech and must be completely cared for by a team of nurses. Under the old definition of objectivity, the doctor could not, except in extreme cases, cease treatment regardless of the prognosis because all human life is objectively equal and therefore sacrosanct. The doctor would in fact probably keep the patient alive despite any living will because the doctor couldn't take personal feelings, including the patient's, into consideration .2 Society in the form of lay-people cannot challenge the authority of the medical establishment, even on fundamentally moral rather than scientific grounds.

Under the new definition offered, the doctor would confer with the family about their wishes regarding the continuation of life. If the patient's wishes regarding this type of situation were known, they would also be taken into consideration. The actual condition and wishes of the patient could actually figure prominently into the consideration of whether or not the patient really ought to be kept alive; such an idea is impossible now. All parties would act with the knowledge that resources being used to keep the patient alive were resources that wouldn't be used to save someone else's life, while at the same time being sensitive to the societal conventions that human life is sacred.

This is not to say that we would all suddenly favor physician assisted suicide were we to adopt this model of objectivity as the standard for assessing the validation of future health care resource allocation critiques. However, at least such issues would enter into the discussion, and not merely as a series of figures or as philosophical absolutes. Objectivity as responsiveness means that each situation would be figured differently, rather than having all situations forced into the same mold.

Examining the current models, we see that the capitalist system loses credibility under this definition of objectivity. Under a system of privatization, there is no reason to take the wider public into account when making decisions. The capitalist system ceases to have any objectivity at all. This is not to say that the capitalist critiques of the current system have no merit, but I would argue that these critiques ought to be reconceptualized in such a way that they can be validated using this new definition of objectivity.

The socialized critique of medicine could survive, but only in a very modified form. Those receiving medical resources would do so with the understanding that they are not automatically entitled by some God-given calculation of entitlement, but rather that these resources represent the perceived responsibilities of other members of society and that the beneficiary would be accountable for their use. While the actual impact this would have on expenditures cannot be predicted, it is nonetheless a markedly different way of viewing current programs such as Medicare and Medicaid.

This definition of objectivity would also mean that the public in general would have to be continually examining their own beliefs and those of others regarding the issue of whom ought to receive what medical resources. Areas of debate that are currently "Off limits," such as nursing home care and physician-assisted suicide, would be open to debate. One could not appeal to a single text or idea, but would have to examine oneself and others, while cost-analysis would occur at the individual rather than the institutional level.

Furthermore, concerns such as organ transplants could no longer be considered the province of "specialists." The wider public can and ought to have a greater say in who shall receive organ transplants, and needs to work with families, physicians, and patients on an individual basis. Public debate would set up the general guidelines under which actual decisions would be made, but this is by no means synonymous with offering sweeping rules that are absolute.

Finally, looking at objectivity as responsibility allows the old definitions of objectivity to be retained to some degree. As I alluded at the beginning, these definitions already inform our validation of critiques. Thus our own moral assessments would still take current forms of objectivity into consideration. We do not entirely lose our old ways of validating arguments, but these ways are augmented by the new.

While not offering a direct solution to the problem of medical resource allocation, this new definition of objectivity does show new ways of viewing it, as well as showing some possible areas for further expansion of inquiry. I am not proposing specific action for change: this must be a community enterprise. I am suggesting that future proposals should respond to the idea of objectivity as accountable responding. It is my belief that the notions of objectivity shape the critiques, because they must be seen as valid by the concerned public. A person developing a critique does so with the knowledge that this critique will be assessed. Adoption of objectivity as responsibility means that new critiques would have to be more context-sensitive: they would have to look at actual situations while still acknowledging that no sweeping critique can tell us all exactly what to do in any situation.


1 Latin for "let the old person beware."
2 This does in fact occur: please see the accompanying sheet.

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