Community Health 106: Health, Ethics, and Policy Fall 2015

574 Boston Ave. Rm 404; Mondays and Wednesdays: 10:30-11:45 AM

Instructor: Professor Keren Ladin, Ph.D., M.Sc. Department of Occupational Therapy Department of Public Health and Community Medicine, TUSM Tufts University

Office: 574 Boston Avenue Room 216 Medford, MA 02155 Email: [email protected] Phone: 617-627-5931 Fax: 617-627-3722 Office Hours: Mondays 1:30-3:00 or by appointment. Course website: https://trunk.tufts.edu/xsl-portal

Teaching Assistant: Alexis Daniels , M.S. Office Hours: By appointment, on Mondays or Wednesdays 12:00-1:00 pm REACH Lab (Suite 118G) Email: [email protected] Note: Please allow 24 hours for a response for emails sent after 9:00 pm.

Course Description

Ethical analysis has become an increasingly integral part of health policy and public health. A foundation in normative ethics and political philosophy is central to policy and medical decision- making because at the core of many policy and medical debates lie questions of distributive justice. This course will focus on evaluating how values, ethical approaches, and evidence should inform policy making, clinical medicine, and public health practice. How should scarce resources, such as organs for transplantation or hospital beds, be allocated? How much personal responsibility do people have and how accountable should they be for their own health and health behaviors? How should public health effectively balance equity and efficiency? Should medicine or public health be specifically concerned with the health of vulnerable or marginalized populations?

This course aims to provide students with the skills necessary for analyzing and contributing meaningfully to current debates in health policy and medicine from an ethics perspective. This course will be taught using a case-method approach. Students will be required to prepare the cases and participate actively in class discussions. Together, we will consider the ethical dimensions of a range of leading issues in public health and health policy, including: organ transplantation, use of cost-effectiveness and comparative effectiveness in coverage decisions,

1 resource allocation for vulnerable populations, personal responsibility for health, and the “right” to health care. Our time together will be spent primarily in discussion and debate, guided by myself and by student discussants that will be leading the ethical analysis of various cases. Students should come to class alert and prepared to engage thoughtfully in case discussions. These experiences will provide insights and practice conducting ethical analysis, and will serve as the basis for exams. Due to this, attendance is mandatory. Readings are categorized as either required or recommended. Required readings will serve as the basis for our class discussions. Recommended readings are intended to provide a more in depth view, and can serve as a guide for students presenting the cases or those who are seeking more background. Unannounced quizzes may be given on required readings only.

Course Aims and Objectives

At the end of this course, students should be able to: 1. Identify the ethical dimensions of health policy, medical, and public health debates 2. Describe several important cases and controversies in public health and leading ethical approaches 3. Critically examine the implications of ethical theories and frameworks for public health and health policy problems 4. Craft a strong and balanced ethical argument both orally and in writing 5. Conduct ethical analysis incorporating normative theories and empirical evidence, presenting logical and defensible resolutions to thorny debates in health policy

Readings

One text is required for this course: Justice by Michael J. Sandel. Other required readings are accessible online, available on the Trunk website, or on reserve at the library.

The following texts are recommended for this course and will be on reserve at the library. We may draw on these resources at times throughout the course to clarify normative theories or to provide more applied examples of how ethical considerations affect public health practice. These books provide more background for those interested in learning more about moral and political philosophy, bioethics, and health policy.

Dawson, Angus (Ed.) Public Health Ethics: Key Concepts and Issues in Policy and Practice. Cambridge: Cambridge University Press, 2011. Available online: http://sgh.org.sa/Portals/0/Articles/Public%20Health%20Ethics%20Key%20- %20Concepts%20and%20Issues%20in%20Policy%20and%20Practice.pdf

Daniels, Norman. Just Health: Meeting Health Needs Fairly. Cambridge University Press. 2008.

Thaler Richard H. and Cass R. Sunstein. Nudge: Improving Decisions About Health, Wealth, and Happiness. New York. Penguin Books, 2009.

Tom L. Beauchamp and James F. Childress. Principles of Biomedical Ethics (Seventh Edition). Oxford: Oxford University Press, 2013.

2 [Website]: Stanford Encyclopedia of Philosophy. http://plato.stanford.edu/

Assignments and Grading

Cases 30% Memo (Due by Nov. 24 at NOON) 15% Presentation 15% Midterm (October 28) 25% Participation (quizzes and class discussions) 10% Final (Assigned Dec. 8, DUE AT NOON DEC. 15) 35%

Note: For students who show significant improvement and consistent effort throughout the course, scores on the final may be more heavily weighted. For example, if a student shows significant improvement between midterm, memo, and final, the final may be more heavily weighted to reflect improvement.

Course Policies and Expectations

Class participation: Research and learning are collaborative processes. Students will be asked to present cases and launch class discussions for certain weeks and to enrich the discourse by contributing regularly. These contributions are invaluable to the learning process and are an integral to success in this course. We look forward to learning from your unique perspectives.

Absences: In fairness to classmates and group members, attendance at all classes is required. Please email the professor and the TF as soon as possible in the case of an anticipated absence. Unexcused absences may negatively impact your grade.

Academic Integrity: Tufts holds its students strictly accountable for adherence to academic integrity. The consequences for violations can be severe. It is critical that you understand the requirements of ethical behavior and academic work as described in Tufts’ Academic Integrity handbook. If you ever have a question about the expectations concerning a particular assignment or project in this course, be sure to ask me for clarification. The Faculty of the School of Arts and Sciences and the School of Engineering are required to report suspected cases of academic integrity violations to the Dean of Student Affairs Office. If there is any suspicion that you have cheated or plagiarized in this class, it will be reported to the dean.

Late Assignments: Given the sequential nature of the assignments, late assignments will not be accepted. All exceptions must be requested by email to me at least 48 hours in advance.

Laptop Policy: Out of respect for all students, we remind you that laptops are only allowed for academic purposes. Misuse of laptops during class for purposes other than academic is distracting and disrespectful to other students.

Incompletes: As a general rule, incompletes will not be granted for this class.

3 Accommodations for students with disabilities: Students needing academic adjustments or accommodations because of a documented disability must present documentation from the Academic Resource Center and speak with the professor by the end of the second week of the term, September 18th. All discussions will remain confidential.

Additional Resources

 Tisch Library: For research assistance- http://www.library.tufts.edu/tisch/subjectLib.html  Academic Resource Center (ARC): For writing and other academic assistance: http://uss.tufts.edu/arc/  The Tufts University Counseling and Mental Health Service (CMHS). For personal and academic concerns- Sawyer House at 120 Curtis Street. 617.627.3360. http://ase.tufts.edu/counseling/

4 Course Schedule

Class Date Topics and Activities Cases (1) Sep 9 Introduction to Ethics and Health Policy (2) Sep 14 Bioethics vs. Public Health: Aims and Jacobson v Massachusetts Approaches (Ladin) (3) Sep 16 Ethical Theory & Reasoning: Trolley Problem (Ladin) Utilitarianism, Libertarianism (4) Sep 21 Ethical Theory & Reasoning: Free markets, Liberalism (5) Sep 23* Special Importance of Health? move to 9/25 (6) Sep 28 Constructing an Ethical Argument: Obamacare and the Ethics of the Workshop 1 Individual Mandate (7) Sep 30 Right to Health Care and Access to Care Colombia Case Guest Speaker: Adriane Gelpi, PhD,MPH (8) Oct 5 Workshop 2 (9) Oct 7 Measuring and Valuing Health Oct 12 NO CLASS- COLUMBUS DAY (10) Oct 14 Rationing and CEA Oregon CEA case (11) Oct 19 CEA Distributive Issues (12) Oct 21 Scarcity and Rationing Allocating Treatment for Ebola

(14) Oct 26 Priority-Setting in Health Care Lung transplantation (15) Oct 28 MIDTERM (16) Nov 2 Disparities: Health Inequity vs. Health Inequality (17) Nov 4 SES and workplace disparities Discussion of Hep C treatment

(18) Nov 9 Geographic stressors Health and Place exercise (19) Nov 10* Race and Gender Disparities Racial disparities in Class on Tues. Guest Speaker: Margie Skeer, ScD, incarceration rates for drug MPH, MSW offenses (20) Nov 16 Quality of Care: Health care disparities (21) Nov 18 Personal Responsibility for Health Case: Medicaid Program (22) Nov 23 Personal Responsibility for Health Obesity and smoking taxes Nov 25 NO CLASS-THANKSGIVING (23) Nov 30 Global Justice (24) Dec 2 Obligations to distant people: prevention Haitian Earthquake vs. rule of rescue

Class Date Topics and Activities Cases (25) Dec 7 Immigrants and Health Care Entitlements Are immigrants entitled to publicly funded care? (26) Dec 9 Research Ethics Community Ethics Board: Transplant and Developmental Disability

September 9th: Introduction to Ethics and Health Policy

Main points:  Course goals and expectations  Case study method

Readings: 1. World Health Organization Definition of Health http://www.who.int/about/definition/en/print.html 2. Sandel, MJ. Justice. Chapter 1 3. Chapter 1: Public Health Ethics: Key Concepts and Issues in Policy and Practice. http://sgh.org.sa/Portals/0/Articles/Public%20Health%20Ethics%20Key%20- %20Concepts%20and%20Issues%20in%20Policy%20and%20Practice.pdf (Read pages 1-5, skim 6-12, read second half of page 12-18.)

September 14th: Principles of Bioethics vs. Principles of Public Health Ethics

Main Points:  Public health priorities vs. bioethics priorities  Goals of public health approach and synthesis with Jacobson case  How to balance individual vs. public interests?  Overview of normative approaches

CASE: Jacobson v Massachusetts 197 US 11(1905)

Readings: 1. Sandel, MJ. Justice. Chapter 2 2. Colgrove J and R Bayer. Manifold Restraints: Liberty, Public Health, and the Legacy of Jacobson v Massachusetts. AJPH. 2005; 95(4) 571-576. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449222/ (Skim this paper –it is an overview for the next two).

6 3. Gostin, LO. Jacobson v. Massachusetts at 100 Years: Policy Power and Civil Liberties in Tension. AJPH. 2005; 95(4):576-581. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449223/ 4. Mariner, WK, Annas GJ, and LH Glantz. Jacobson v Massachusetts: It’s not your Great- Great-Grandfather’s Public Health Law. AJPH. 2005; 95(4) 581-590. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449224/

Recommended Readings: 1. Ruger, J. Ethics in American Health 1: Ethical Approaches to Health Policy. AJPH. 2008;98(10):1751-1756. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636453/ 2. Gostin, LO. Tradition, Profession, and Values in Public Health. In “Ethics and Public Health Model Curriculum” (Eds. Jennings et al.). 2003. Read Pgs 13-36 (online). (NOTE: This is a helpful basic overview of a public health approach. It outlines some of the goals of public health ethics and ways of evaluate potential solutions.)

September 16th: Ethical Theory and Reasoning I

Main points:  What theories can guide our deliberations about public health ethics? o Utilitarianism o Libertarianism

CASE: Trolley Problem (in Justice); http://www.philosophyexperiments.com/fatman/Default.aspx

Readings: 1. Sandel, MJ. Justice. Chapters 3 and 4 2. Darwall, SL. “Chapter 2: Theories of Ethics” in A Companion to Applied Ethics (Frey RG and CH Wellman, Eds). (online)

Recommended Readings: 3. Brulde, B. “Chapter 2: Health, disease, and the goal of public health”. In Public Health Ethics: Key Concepts and Issues in Policy and Practice. http://sgh.org.sa/Portals/0/Articles/Public%20Health%20Ethics%20Key%20- %20Concepts%20and%20Issues%20in%20Policy%20and%20Practice.pdf (you can skip the discussion of HALEs mid 24-33)

September 21st: Ethical Theory and Reasoning II

Main points:  What theories can guide our deliberations about public health ethics? o Free Markets

7 o Liberalism (Liberal Egalitarianism) o Theories of Justice

Readings: 1. Sandel, MJ. Justice. Chapters 5 and 6. 2. Norman Daniels, “Three Questions of Justice” – Chapter 1 of Just Health Cambridge U. Press), 2007 (online)

Recommended Readings: 3. Julian Lamont and Christi Favor, “Distributive Justice”, in the online Stanford Encyclopedia of Philosophy. http://plato.stanford.edu/ (online) 4. Leif Wenar, “John Rawls”, section 4, in the online Stanford Encyclopedia of Philosophy. (online)

September 25th: Special Importance of Health NOTE: Class will meet Friday, September 25th due to the Holiday

Main Points:  Is health of special importance?  Review of normative theories

Readings: 1. Daniels, N. “What Is the Special Moral Importance of Health?” -- Chapter 2 of Just Health (Cambridge U. Press), 2007, pp. 29-70 (online) 2. Sen, A. “Why Health Equity?” Health Economics 11: 659-666, 2002. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/12457367 3. CEJA Report 7 – I-93. Ethical Issues in Health Care Systems Reform: The Provision of Adequate Health Care. www.google.com/url?q=http://www.ibrarian.net/navon/paper/Ethical_Issues_in_Health_Care _Systems_Reform__The.pdf%3Fpaperid%3D17298974&sa=U&ei=eywBVKzLNY6wggSI_ IKIAw&ved=0CB8QFjAC&sig2=7xnPgnQAbL38JWSDLF-BUw&usg=AFQjCNGxv- aopaPjMPDy4klAxjY6fLGTpw 4. Persad G, Wertheimer A, and EJ Emanuel. Principles for allocation of scarce medical interventions. The Lancet. 2009;373:423-431. http://bme.ccny.cuny.edu/faculty/mbikson/Courses/BMESeniorDesign/EthicsOfHealthRation ing.pdf

Recommended Readings: 5. Committee on Defining and Revising an Essential Health Benefits Package for Qualified Health Plans. (2012). Essential Health Benefits: Balancing Coverage and Cost. Institute of Medicine. (Executive summary)

8 September 28th: Morality and health insurance Workshop 1: Crafting an ethical argument I

CASE: PPACA and the universal mandate  Should everyone be guaranteed access to affordable health care?  What ethical arguments can be made for and against mandating health insurance?  Nuts and bolts of health insurance

WORKSHOP

Main points:  How to conduct a balanced analysis while making a strong argument  Don’t tear down a straw man, be thoughtful about addressing objections

CASE: The PPACA (Obamacare): Should we mandate universal coverage?

Readings:

1. Parmet, WE. The individual mandate: Implications for public health law. J Law, Med, and Ethics. 2011; 39:401-413. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/21871038 2. The Heritage Foundation. The Case Against Obamacare. Read pgs 1-9; 31-35; 61-63. http://www.heritage.org/research/projects/the-case-against-obamacare 3. Rulli T, Emanuel AJ, Wendler D. The moral duty to buy health insurance. JAMA 2012:137-8. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.ni h.gov/pubmed/22782412 4. Daniels N, Saloner B, and AH Gelpi. Access, Cost, and Financing: Achieving an Ethical Health Reform. Health Affairs. 2009; 28(5): w900-w916. http://content.healthaffairs.org/content/28/5/w909.long

Recommended Readings: 5. Ruger, JP. The moral foundations of health insurance. Q J Med 2007:100:53-57. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/17178735 6. Hall MA. Supreme Court arguments on the ACA – a clash of two world views. N Engl J Med 2012; 366:1462-1463. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/?term=Supreme+Court+arguments+on+the+ACA+%E2%80%93+a+clash+of+tw o+world+views

9 September 30th: Right to Health Care and Access to Care

GUEST LECTURER: Adriane Gelpi, Ph.D., MPH, University of Miami Main Points:  Is there a right to health care?  At what cost should health care be provided to all? How much care?  What are reasonable constraints on health care provision?  How should resource allocation be prioritized?

CASE: EQUITABLE HEALTH REFORM IN COLOMBIA

Readings:

1. Daniels, N. and Gelpi, A. (2009a.) Achieving Equitable Health Reform in Colombia: Colombia’s Constitutional Court Order to the Ministry of Social Protection. (Unpublished). (This reading is under the “Cases” folder. This will serve as the basis for the case discussion - online) 2. Gruskin S, Daniels N. Justice and human rights: Priority setting and fair deliberative process. American Journal of Public Health. 2008; 98;1573-1577. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2509612/ 3. Yamin AE, Parra-Vera O. How do courts set health policy? The case of the Colombian Constitutional Court. PLoS Med 2009;6(2):e1000032. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000032

Recommended Readings:

1. Biehl H, Amon JJ, Socal MP, Petrvna A. Between the court and the clinic: lawsuits for medicines and the right to health in Brazil. Health and Human Rights 2012;14(1). http://www.hhrjournal.org/wp-content/uploads/sites/13/2013/06/Biehl-FINAL2.pdf 2. Meier BM, Gable L. US efforts to realise the right to health through the Patient Protection and Affordable Care Act. Human Rights Law Review 2013. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2171095

October 5th: Workshop 2: Ethical Analysis Crafting an Argument II

WORKSHOP: Alexis Daniels, MSc

Main Points:  Identifying an ethical argument  The importance of using supporting evidence for argumentation  Difference between argument and analysis  Critiquing literature

Readings:

1. Roberts MJ and MR Reich. Ethical Analysis in Public Health. The Lancet. 2002;359:1055- 1059. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/11937202 2. Gladwell, M. “The Moral Hazard Myth”. The New Yorker. August 29, 2005. http://www.newyorker.com/archive/2005/08/29/050829fa_fact 3. Smedley, B.D. (2008). Moving beyond access: achieving equity in state health care reform. Health Affairs. (2008) 27(2): 447-55. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/18332501

October 7th: Measuring and Valuing Health

Main points:  Given various definitions of health, how should we measure it?  Depends on valuation  Strengths and weaknesses of different measures (QALY, DALY, vignettes, others)

Video: Joshua Salomon, “Common Values for Health Outcomes”, 2011. http://webapps.sph.harvard.edu/accordentG3/joshsalomon-20111201/index.htm#

Readings:

1. Reinhart, Uwe, “Pricing Human Life (-Years). Economix Blog, March 20, 2009. http://economix.blogs.nytimes.com/2009/03/20/pricing-human-life-years/ 2. Institute of Medicine (2006). Valuing Health: CEA in Regulatory Settings. (Ch 4). (This is a very cursory overview of the ethical issues in CEA and CBA). 3. Hausman, D. (2006). Valuing Health. Philosophy and Public Affairs 34(3): 246-74. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/19301348 4. Nord, E., Daniels, N. and Kamlet, M. (2009), QALYs: Some Challenges. Value in Health, 12: S10–S15. doi: 10.1111/j.1524-4733.2009.00516.x http://www.ispor.org/meetings/invitational/QALY/Paper3.pdf

Recommended Readings:

5. Cutler, DM and E Richardson. “Chapter 5: The value of health and what affects it” in Your Money and Your Life. 1999. P. 99-132. http://www.nber.org/chapters/c9848.pdf (skim) 6. Nord, E., Enge, AU, Gundersen V. (2010), QALYs: is the treatment proportional to the size of the Gain? Health Econ, 19(5): 596-607. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/19459186

11 7. Menzel, P., Gold, M.R., Nord, E., Pinto-Prades, J.L., Richardson, J., Ubel, P. (1999). Toward a Broader View of Values in Cost-Effectiveness Analysis of Health. Hastings Center Report 29(3): 7-15. http://www.nyu.edu/gsas/dept/philo/courses/bioethics/Papers/HCR28Feb99.PDF 8. Dolan, P., et al. (2005). QALY maximisation and people’s preferences: a methodological review of the literature. Health Econ. 14(2): 197-208. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/15386656 9. Arnesen, T., Nord, E (1999). The value of DALY life: problems with ethics and validity of disability adjusted life years. BMJ 319: 1424-25. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/10574867

October 12th NO CLASS – COLUMBUS DAY

October 14th: Rationing and CEA I- Lessons From the Oregon Health Plan

Main Points:  How do rationing decisions get made in practice?  Potential pitfalls of using CEA

CASE: Oregon Health Plan (from Ethics and Public Health Model Curriculum)

Readings:

1. Bodenheimer, Thomas, “The Oregon Health Plan—Lessons for the Nation” First and Second Parts. New England Journal of Medicine, 1997. https://facultystaff.richmond.edu/~bmayes/pdf/oregon_i.pdf ; Part 2: https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/9278472 2. Hadorn, D.C. (1991). Setting Health Care Priorities in Oregon. JAMA 265(17): 2218-25. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/1901610 3. Garland M, Stull J. Public health and health system reform: access, priority setting, and allocation of resources. ASPH: Ethics and Public Health Model Curriculum, 2003: 244 -251. (online) This chapter presents a framework for conducting the ethical analysis in this case. 4. Daniels N. (1991). Is the Oregon Rationing Plan Fair? JAMA 265(17): 2232-2235. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/2013956

Recommended Readings: 1. Jacobs L, Marmor T, Oberlander J. The Oregon Health Plan and the political paradox of rationing: What ... Journal of Health Politics, Policy and Law. 1999; 24(1):161-180.

October 19th: Scarcity and Rationing: CEA and Distributive Justice Concerns

Main points:  How should we prioritize health resources?  Ethical considerations for the use of CEA/CBA and comparative effectiveness  Should we count indirect benefits or costs in CEA?

CASE: Oregon case continued

Readings:

1. Brock, D. (2003). Separate Spheres and Indirect Benefits. Cost-Effectiveness and Resource Allocation 1:4 (published online 26 February 2003). https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/12773217 2. Brock, D. (2003). Ethical Issues in the Use of Cost Effectiveness Analysis for the Prioritization of Health Care Resources. In Khusfh, G. and Englehardt T., (Eds.) Bioethics: A Philosophical Overview. Dordrecht: Kluwer Publishers. http://www.nyu.edu/gsas/dept/philo/courses/bioethics/Papers/EthicalIssues.PDF 3. Oberlander, J. Health reform interrupted: The unraveling of the Oregon Health Plan. Health Affairs. 2007;26:w96-w105. http://content.healthaffairs.org/content/26/1/w96.full 4. Four Unsolved Rationing Problems a. Daniels, N. et al. (1994). Four Unsolved Rationing Problems: A challenge. Hastings Center Report 24(4): 27-29. (online) b. Kamm, F.M. (1994). To Whom? Hastings Center Report 24(4): 29-32. (online) c. Rakowski, E. (1994). The Aggregation Problem. Hastings Center Report 24(4): 33- 36. (online) d. Bailey, M.A. (1994). The Democracy Problem. Hastings Center Report 24(4): 39-42. (online)

October 21st: Scarcity and Rationing I: Allocating treatment for Ebola

Main Points:  Debating fair chances vs. best outcomes  Review of rationing problems  Natural vs. artificial scarcity

CASE: Allocating Ebola treatment during the 2014 Ebola outbreak Also read: http://www.nytimes.com/roomfordebate/2014/12/01/experimental-drugs-and-the- ethics-of-fighting-ebola

Readings:

1. McGough LJ, Reynolds SJ, Quinn TC, and JM Zenilman. Which patients first? Setting priorities for antiretroviral therapy where resources are limited. AJPH. 2005;95:1173-1180. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449336/ 2. Practical, Legal, and Ethical Issues in Expanded Access to Investigational Drugs Jonathan J. Darrow, S.J.D., J.D., M.B.A., Ameet Sarpatwari, J.D., Ph.D., Jerry Avorn, M.D., and Aaron S. Kesselheim, M.D., J.D., M.P.H. N Engl J Med 2015; 372:279-286 http://www.nejm.org/doi/full/10.1056/NEJMhle1409465 3. Fauci, A. S. (2014). Ebola — Underscoring the Global Disparities in Health Care Resources. New England Journal of Medicine, 371(12), 1084-1086. doi: 10.1056/NEJMp1409494 http://www.nejm.org/doi/full/10.1056/NEJMp1409494?query=OF 4. Rid, A and EJ Emanual. Ethical considerations of experimental interventions in the Ebola outbreak. The Lancet, 2014;384:1896–1899. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61315-5/abstract

Recommended Readings:

1. Pollack, Andrew. Opting against Ebola drug for ill African doctor. The New York Times. August 12, 2014. http://www.nytimes.com/2014/08/13/world/africa/ebola.html?hp&action=click&pgtype=Ho mepage&module=first-column-region®ion=top-news&WT.nav=top-news&_r=0 2. World Health Organization. Ethical considerations for use of unregistered interventions for Ebola viral disease: Report of an advisor panel to WHO. August 2014. http://apps.who.int/iris/bitstream/10665/130997/1/WHO_HIS_KER_GHE_14.1_eng.pdf?ua= 1 3. Kjell Arne Johansson & Ole Frithjof Norheim (2011) Problems With Prioritization: Exploring Ethical Solutions to Inequalities in HIV Care, The American Journal of Bioethics, 11:12, 32-40. http://dx.doi.org/10.1080/15265161.2011.627287 4. Farrar, J. J., & Piot, P. (2014). The Ebola Emergency — Immediate Action, Ongoing Strategy. New England Journal of Medicine, 140922210513002. doi: 10.1056/NEJMe1411471 http://www.nejm.org/doi/full/10.1056/NEJMe1411471?query=OF 5. Frieden, T. R., Damon, I., Bell, B., Kenyon, T., & Nichol, S. (2014). Ebola 2014 — New Challenges, New Global Response and Responsibility. New England Journal of Medicine, 1- 3. doi: 10.1056/NEJMp1409903 http://www.nejm.org/doi/full/10.1056/NEJMp1409903?query=OF 6. Wolz, A. (2014). Face to Face with Ebola — An Emergency Care Center in Sierra Leone. New England Journal of Medicine, 371(12), 1081-1083. doi: 10.1056/NEJMp1410179 http://www.nejm.org/doi/full/10.1056/NEJMp1410179?query=OF

October 26th: Scarcity and Rationing II: Priority-Setting in Health

Main Points:

14  How should a naturally scarce resource be allocated?  Priority for worst-off, best outcome, deservingness  Balancing equity and efficiency

CASE: Murnaghan v. Sebelius http://www.paed.uscourts.gov/documents/opinions/13d0477p.pdf http://www.paed.uscourts.gov/documents/opinions/13d0484p.pdf

Readings:

1. Ladin K and DW Hanto. Rationing Lung Transplants—Procedural Fairness in Allocation and Appeals. NEJM. 2013;369:599-601. http://www.nejm.org/doi/full/10.1056/NEJMp1307792 (podcast also available online) 2. Turning wrong into right: The 2013 lung allocation controversy. Ann Int Med. 2013. http://annals.org/article.aspx?articleid=1699958 3. Harvey SG. Comment response from the plaintiff’s lawyer. (see link above)

Recommended Readings: 4. UNOS. Questions and Answers for Transplant Candidates about Lung Allocation Policy. http://www.unos.org/docs/Lung_Patient.pdf 5. Kamm FM (1985). Equal Treatment and Equal Chances. Philosophy and Public Affairs 14, no. 2:177-94. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.jstor.org/discov er/10.2307/2265456?uid=3739696&uid=2134&uid=2&uid=70&uid=4&uid=3739256&sid=2 1102627142473 6. Broome, J. (1994). Fairness versus Doing the Most Good. Hastings Center Report 24(4): 36- 9. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/7960705

October 28th: MIDTERM

No reading for this class- Good luck on the exam! 

November 2nd: Disparities: When is a Health Inequity a Health Inequality?

Main Points:

 Definition of health inequity versus health inequality  When is a health inequality unjust?  Is every variation in health unjust?

Readings:

1. Wilson, J. “Health Inequalities” in Public Health Ethics (Dawson, A, Eds.). 2011. Cambridge University Press. Cambridge. (online) 2. Daniels, Norman. “Chapter 3: When are health inequalities unjust? The social determinants of health” in Just Health. Cambridge University Press. New York 2008. (Online). 3. Whitehead, Margaret. "The Concepts and Principles of Equity and Health." International Journal of Health Services 22 (1992): 429-45. http://salud.ciee.flacso.org.ar/flacso/optativas/equity_and_health.pdf

Recommended Readings:

1. Gwatkin, D.R. “Health inequalities and the health of the poor: What do we know? What can we do?” Bulletin of the World Health Organization 78 (2000): 3-18. http://www.who.int/bulletin/archives/78(1)3.pdf 2. Paula Braveman. Health Disparities and Health Equity, Annual Rev Pub Health 27(2006):167-94 https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/16533114 3. Murray C.J., Gakidou E.E., J. Frenk. “Health inequalities and social group differences: What should we measure?”. Bulletin of the World Health Organization. 77(1999):537-543. http://www.who.int/bulletin/archives/77(7)537.pdf

November 4th: Disparities: Socioeconomic Status and Class Disparities

Main Points:

 Is there evidence for well-established SES disparities?  Do mechanisms impart moral relevance?  Define absolute versus relative deprivation

CASE DISCUSSION: Treatment of Hepatitis C and Opioid use

1. From local headlines: Brewster, A. “The Face of Opioid Addiction: Vinnie, A ‘Regular’ Guy From Revere.” WBUR. 4 Sept. 2015. Retrieved from http://commonhealth.wbur.org/2015/09/opioid-addiction- vinnie?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=n prnews&utm_content=20150905 2. Sweeney, C. “How the Heroin Crisis Ushered in a Hepatitis C Epidemic.” Boston Magazine. 11 August 2015. Retrieved from http://www.bostonmagazine.com/health/blog/2015/08/11/heroin-hepatitis-c/

Readings: (most are very brief)

16 1. Edlin, B.R., Seal, K.H., Lorvick, J., Kral, A.H., Ciccarone, D.H., Moore, L.D., et al. (2001). Is it justifiable to withhold treatment for hepatitis C from illicit-drug users?. New England Journal of Medicine, 345 (3):211-215. http://www.ncbi.nlm.nih.gov/pubmed/11463019 2. Ho, D. “When Good Organs Go to Bad People.” Bioethics 2008; 22(2):77-83. https://porterewhs.pbworks.com/w/file/fetch/89849561/Liver%20When%20good%20organs %20go%20to%20bad%20people.pdf 3. Sacchini, D., et al. “Ethical assessment of hepatitis C virus treatment: The lesson from first generation protease inhibitors.” Digestive and Liver Disease 2015; 47(5):351-355. http://www.dldjournalonline.com/article/S1590-8658(14)00805-6/abstract 4. Nayak, R.K., and Steven D. Pearson. “The Ethics Of ‘Fail First’: Guidelines And Practical Scenarios For Step Therapy Coverage Policies.” Health Affairs 2014; 33(10):1779-1785. http://content.healthaffairs.org/content/33/10/1779.short 5. Canary LA, Klevens RM, and SD Holmberg. “Limited Access to New Hepatitis C Virus Treatment Under State Medicaid Programs.” Annals of Internal Medicine 2015: 1-4. http://nvhr.org/sites/default/files/.users/u27/canary.pdf 6. Brennan, R. and W. Shrank. “New Expensive Treatments for Hepatitis C Infection.” JAMA 2014:EI-E2. http://bibliobase.sermais.pt:8008/BiblioNET/Upload/PDF7/005169.pdf

Recommended Readings: (more broadly about socioeconomic disparities)

1. Fry CL, Treloar C, and L Maher. “Ethical challenges and responses in harm reduction research: promoting applied communitarian ethics.” Drug and Alcohol Review. 2005; 24:449-459. https://www.researchgate.net/profile/Lisa_Maher/publication/7469489_Ethical_challenge s_and_responses_in_harm_reduction_research_promoting_applied_communitarian_ethic s/links/0deec51b80ab6e116e000000.pdf 2. Aronsohn, A. and Jensen, D. (2012), Informed deferral: A moral requirement for entry into the hepatitis C virus treatment warehouse. Hepatology, 56: 1591–1592. http://onlinelibrary.wiley.com/doi/10.1002/hep.25957/full 3. http://www.nature.com/ajg/journal/v106/n10/abs/ajg2011219a.html (abstract) 4. Marmot, M.G., and Martin J. Shipley. "Do Socioeconomic Differences in Mortality Persist after Retirement? 25 Year Follow up of Civil Servants from the First Whitehall Study." BMJ 313.9 November (1996): 1177-80. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.ni h.gov/pubmed/8916748 5. Marmot, M.G., et al. "Employment Grade and Coronary Heart Disease in British Civil Servants." Journal of Epidemiology and Community Health 32 (1978): 244-49. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.ni h.gov/pubmed/744814 6. Folbre, N. “Born to Lose: Health Inequality at Birth”. The New York Times. June 27, 2011. (NOTE: PLEASE FOCUS ON FACTORS OTHER THAN RACE). http://economix.blogs.nytimes.com/2011/06/27/born-to-lose-health-inequality-at-birth/ 7. Deaton, A. What does empirical evidence tell us about the injustice of health inequalities? 2011. Princeton University.

17 http://www.princeton.edu/rpds/papers/What_does_the_empirical_evidence_tell_us_about _the_injustice.pdf 8. Wilkinson, RG and KE Pickett. Income Inequality and Social Dysfunction. Annual Review of Sociology. 2009;35:493-511. http://www.hks.harvard.edu/inequality/Seminar/Papers/Wilkinson12.pdf 9. Murray CJ, Kulkami SC, Michaud C, Tomjima N, Bulzacchelli MT, Iandiorio TJ, and M Ezzati. Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States. Plos Medicine. 2006;3:e260 (skim) .http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030260 10. Pappas, G. Geographic data on health inequities: Understanding policy implications. Plos Medicine. 2006. 3;9:e357. (Skim) http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0030357

November 9th: Environmental, Workplace, and Social Stressors

Main Points:

 Is there evidence for well-established SES disparities?  Do mechanisms matter?  What environmental and contextual factors negatively impact health? Are they modifiable? Chosen?

CASE: Health and Place exercise

Readings:

1. Why Place Matters: Building A Movement for Healthy Communities, PolicyLink http://www.policylink.org/sites/default/files/WHYPLACEMATTERS_FINAL.PDF 2. Where We Live Matters for Our Health: The Links Between Neighborhoods and Health. Robert Wood Johnson Commission for a Healthier America http://www.commissiononhealth.org/PDF/888f4a18-eb90-45be-a2f8- 159e84a55a4c/Issue%20Brief%203%20Sept%2008%20- %20Neighborhoods%20and%20Health.pdf 3. Where We Live Matters for Our Health: The Links Between Housing and Health. Robert Wood Johnson Commission for a Healthier America. http://www.commissiononhealth.org/PDF/033756c1-3ee3-4e36-bb0e- 557a0c5986c3/Issue%20Brief%202%20Sept%2008%20- %20Housing%20and%20Health.pdf

Recommended Readings:

4. Semmer, Norbert K. (2007) Stress at the Work Place, Universität Bern, WHO, Geneva, 14 February 2007. http://www.who.int/occupational_health/topics/stressatwp/en/index.html

18 5. Melin, B. et al. (1999). Psychological and physiological stress reactions of male and female assembly workers: a comparison between two different forms of work organization. J of Org Behavior 20: 47-61. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.jstor.org/stable/3 100203 6. Kivimäki, M. et al. (2012). Job Strain as a Risk Factor for Coronary Heart Disease: a Collaborative Meta-analysis of Individual Participant Data. Lancet, 380:9852, 27: 1491- 1497. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3486012/

November 10th: Racial Disparities Note: Class meets on Tuesday the 10th, not Wednesday

Guest Speaker: Margie Skeer, ScD, MSW, Tufts University School of Medicine

Main Points:

 Is there evidence for well-established racial/SES disparities?  How do historical patterns of social disadvantage relate to the current distribution of health, wealth, and opportunity for different groups of people?  Would health differences persist with equal treatment? Would they be morally questionable?

CASE: RACIAL DISPARITIES IN INCARCERATION RATES FOR DRUG OFFENSES

Note: Readings for the case and the case description will be assigned shortly.

Readings:

1. Williams DR and PB Jackson. Social sources of racial disparities in health. Health Affairs. 2005;24:325-334. http://content.healthaffairs.org/content/24/2/325.full.pdf+html 2. Prewitt, K. “Fix the census’s archaic racial categories”. The New York Times. August 21, 2013. http://www.nytimes.com/2013/08/22/opinion/fix-the-census-archaic-racial- categories.html

Recommended Readings:

3. Ladin K, Hanto DW. Understanding disparities in transplantation: do social networks provide the missing clue? Am J Transplant. 2010 Mar; 10(3):472-6. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/20055801 4. Cooper, Richard S., Jay S. Kaufman, and Ryk Ward. "Race and Genomics." New England Journal of Medicine 348.12 (2003): 1166-70. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.gov/pu bmed/12646675

19 5. Chicago Tribune, Study: Race gap in African-American cancer deaths may be partly biological, July 2009.http://articles.chicagotribune.com/2009-07- 08/news/0907070369_1_breast-cancer-lung-cancer-adult-cancer-patients 6. Ladin, K, Rodrigue JR, and DW Hanto. Framing disparities along the continuum of care from chronic disease to transplantation: Barriers and interventions. Am J Transplant. 2009;9:669-674. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697924/ 7. Reese PP, Nair M, RD Bloom. Racial disparities in access to living donor kidney transplantation How can centers do better? American Journal of Kidney Diseases. 2012; 59 (6): 751-753. http://www.ajkd.org/article/S0272-6386%2812%2900564-1/fulltext

November 16th: Healthcare Disparities

Main points:  Are all patients treated fairly?  Statistical discrimination  Cultural competence

Readings:

1. Schulman, K. A., et al. "The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization." New England Journal of Medicine 340.8 (1999): 618-26. http://psg- mac43.ucsf.edu/ticr/syllabus/courses/5/2002/10/22/Lecture/readings/Schulman_NEJM_race_catheter. pdf 2. Schwartz, Lisa M., Steven Woloshin, and H. Gilbert Welch. "Misunderstandings about the Effects of Race and Sex on Physicians' Referrals for Cardiac Catheterization." New England Journal of Medicine 341 (1999): 279-83. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/10413743 3. Vaccarino V, et al. “Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002.” New England Journal of Medicine. 2005 Aug 18;353(7):671- 82. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.gov/pubme d/16107620 4. Casalino LP, Elster A Eisenberg A, Lewis E, Montgomery J, D Ramos. Will pay-for- performance and quality reporting affect health care disparities? Health Affairs. 2007;26:w405-414. http://content.healthaffairs.org/content/26/3/w405.full.pdf+html

Recommended Readings:

1. Bloche, MG. (2004) Health Care Disparities: Science, Politics, and Race. New England Journal of Medicine, 350, No. 15: 1568-70. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/15071133 2. Henig, RM. (2004) The Genome in Black and White (and Gray). The New York Times. New York: 47. http://www.nytimes.com/2004/10/10/magazine/10GENETIC.html

November 18th: Personal Responsibility for Health

Main points:  How responsible are people for their own health/health behaviors/utilization?  Are people who make bad decisions that lead poor outcomes more morally culpable than those who have poor outcomes do to chance?  Is it ethical to incentivize certain groups towards preferred behaviors?

CASE: West Virginia Medicaid Incentives (online)

Watch: http://www.pbs.org/wnet/religionandethics/2007/10/26/october-26-2007-responsible- medicaid-patients/4496/

Readings:

1. Families USA (2008). “Mountain Health Choices: An Unhealthy Choice for West Virginians.” research.policyarchive.org/15678.pdf 2. Wikler, D. (2002). “Personal and Social Responsibility for Health.” Ethics and International Affairs 16: 47-56. (online) 3. Bishop, G and AC Brodkey. Personal responsibility and physician responsibility- West Virginia’s Medicaid Plan. NEJM. 2006;335:756-758. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.go v/pubmed/16928992 4. Smith, DG. Health care reform in West Virginia: A lesson from the states. Heritage Foundation Web Memo 2582. August 7, 2009. http://www.heritage.org/research/reports/2009/08/health-care-reform-in-west-virginia-a- lesson-from-the-states

Recommended Readings:

5. “Bad Blood” series from New York Times: a. Kleinfeld NR. Living at an epicenter of diabetes, defiance and despair. NY Times, Jan. 10, 2006. http://nyshealthfoundation.org/resources-and-reports/resource/bad- blood-series-new-york-times b. Urbina I. In the treatment of diabetes, success often does not pay. NY Times, Jan. 11, 2006. Access online. c. Santora M. East meets west, adding pounds and peril. NY Times, Jan 12, 2006. Access online. 6. Schmidt, H. Health responsibility, the Left and the Right. Hastings Center Blog. http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=440 7. Steinbrook, R. Personal responsibility for health. NEJM. 2006; 355:753-756. http://www.nejm.org/doi/full/10.1056/NEJMp068141

November 23rd: Personal Responsibility for Health

Main points:

 What is “libertarian paternalism? What is a “nudge”?  Is libertarian paternalism an oxymoron?  Does libertarian paternalism emerge from new scientific research findings? Which?

CASE: Obesity taxes and workplace wellness initiatives: the nanny state?

Readings:

1. Cass Sunstein and Richard Thaler, “Libertarian Paternalism is not an Oxymoron,” University of Chicago Law Review 70(4), 2003, pp. 1159-1202 https://www.bostonfed.org/economic/conf/conf48/papers/thaler.pdf 2. Daniel Hausman and Brynn Welch, “Debate: To Nudge or Not to Nudge”. Journal of Political Philosophy 18(1), 2010, pp. 123-136 https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://onlinelibrary.wiley.co m/doi/10.1111/j.1467-9760.2009.00351.x/full 3. Brownell KD, Kersh R, Ludwig DS, Post RC, Pul RM, Schwartz MB, WC Willett. Personal responsibility and obesity: A constructive approach to a controversial issue. Health Affairs. 2010;29:379-387. http://content.healthaffairs.org/content/29/3/379.full.pdf+html 4. Kolbert, E. (2009). XXXL. The New Yorker, 85:21(July 20): 73-77 http://www.newyorker.com/arts/critics/books/2009/07/20/090720crbo_books_kolbert 5. Bittman, M. (2012) Stop Subsidizing Obesity. NY Times, December 25, 2012. http://opinionator.blogs.nytimes.com/2012/12/25/stop-subsidizing-obesity/?emc=eta1

Recommended Readings:

5. Bitton, A., Green, C., and Colbert, J. (2011). Improving the Delivery of Global Tobacco Control, Mount Sinai Journal of Medicine 78: 382–393. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.g ov/pubmed/21598265 6. Feachem, R. and Sabot, O. (2008). A New Global Malaria Eradication Strategy: Viewpoint, Lancet 371(9624): 1633–35. http://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(08)60424-9/fulltext#article_upsell 7. Smith, D.L. Cohen, J.M., Moonen, B., Tatem, A.J., et al. (2011). Solving the Sisyphean Problem of Malaria in Zanzibar, Science 332(6036): 1384-5. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.ncbi.nlm.nih.g ov/pubmed/21680828 8. Makwiza, I., Nyirenda L., Goma F., Hassan F., Chingombe I,, Bongololo, G. , Theobald, S. (2006) Equity and Health System Strengthening in ART roll out: An analysis from literature review of experiences from east and southern Africa. Equinet 38; http://web.idrc.ca/uploads/user-S/11640987341EQUINET_- _ART_Equity_Review_Final.pdf

December 2nd: Obligations to distant people—Prevention vs. Rule of Rescue

Main points:  If we do have obligations to distant people, how can we decide how and where to assist?  Does the rule of rescue trump prevention?

23  How does this relate to statistical versus identified victims?

CASE: Haiti Earthquake crisis

Readings:

1. Singer, P. (1972). Famine, Affluence and Morality, Philosophy and Public Affairs 1: 229-43. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.jstor.org/stable/ 2265052 2. Miller, R. (2004). Beneficence, Duty and Distance, Philosophy and Public Affairs 32: 357- 83. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.jstor.org/stable/ 3557993 3. Reitman, J. (2011) How the World Failed Haiti, Rolling Stone August 4, 2011. http://www.rollingstone.com/politics/news/how-the-world-failed-haiti-20110804 4. Buchanan, A. E. (1984). The Right to a Decent Minimum Health Care. Philosophy and Public Affairs 13(1): 55-57, 66-78. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.jstor.org/stable/2265199

Recommended Readings:

1. Noele, C. A Responsibility to Protect in Libya, Global Policy February 24, 2011. http://www.globalpolicyjournal.com/blog/24/02/2011/responsibility-protect-libya 2. Barnett, M. (2005) ‘Humanitarianism transformed’, Perspectives on Politics 3(4): 723– 740. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.jstor.org/stable/ 3688176

December 7th: Immigrants and Health Care Entitlements

Main points:

This week will discuss the implications of global movement of peoples, and the moral relevance of borders, as it relates to the provision of health care. We will focus on examining the treatment of immigrants in the Patient Protection and Affordable Care Act (PPACA). The public debate over whether immigrants deserve entitlements has shaped the way health care benefits have been allocated in the United States, most recently through PPACA. Though there are political barriers to expanding coverage to immigrants (for many reasons), the question of whether immigrants should have rights to health care and other social services is a normative one.

 Do immigrants have a right to public programs to which they contribute through taxes? (ex. Medicare and Social Security)  Is the right contingent upon legal status?

24  Who should pay for health care for this population? Should financing of health care for immigrants be separate from health care for other vulnerable populations who cannot afford care?  We will aim to address these questions, and also grapple with the rights of immigrants in the larger context of the rights of people to migrate and the role of nations in protecting and preserving their borders.

Readings:

1. Kaiser Commission on Medicaid and the Uninsured. (2004). Health coverage for immigrants. Washington, D.C.: Kaiser Foundation. http://kaiserfamilyfoundation.files.wordpress.com/2013/01/health-coverage-for-immigrants- fact-sheet.pdf (skim) 2. Sommers, BD. Stuck between health and immigration reform—Care for undocumented immigrants. N Eng J Med. 2013; 369:593-595. http://www.nejm.org/doi/full/10.1056/NEJMp1306636 3. Daniels N and K Ladin. “Immigration and Access to Health Care”. In Routledge Companion to Bioethics. Arras K, Kukla R, and E. Fenton (Editors). 2014. Taylor & Francis/Routledge. New York. (https://books.google.com/books?id=vUa2BQAAQBAJ&pg=PA459&lpg=PA459&dq=Dani els+N+and+K+Ladin.+“Immigration+and+Access+to+Health+Care”.+In+Routledge+Compa nion+to+Bioethics.&source=bl&ots=f0ZeWL74T9&sig=DsP8NeiZVZMHdX00liK07pd3nG I&hl=en&sa=X&ved=0CC4Q6AEwAmoVChMI_Y2nh4PmxwIVAxs- Ch2VjQXz#v=onepage&q=Ladin&f=false, go to page 56)

Recommended Readings:

1) Massey, D.S. (2007). Understanding America's Immigration 'Crisis,’ Proceedings of the American Philosophical Society 151(3): 309-327. http://www.uky.edu/AS/PoliSci/Peffley/QIPSR%20files/Massey- understanding.immigration.crisis.aps.pdf (skim) 2) Parmet, WE. Holes in the safety net—Legal immigrants’ access to health insurance. N Engl J Med. 2013;369:596-598. http://www.nejm.org/doi/full/10.1056/NEJMp1306637?viewType=Print&viewClass=Print 3) Dwyer, J. (2004). Illegal immigrants, health care, and social responsibility, The Hastings Center Report 34(1): 34-41. https://www.library.tufts.edu/ezproxy/ezproxy.asp?LOCATION=http://www.jstor.org/stable/ 3528249 4) Siskin, A. (2011). Treatment of Noncitizens Under the Patient Protection and Affordable Care Act, CRS Report for Congress, March 22, 2011. http://www.nafsa.org/uploadedFiles/CRS%20analysis%20re%20noncitizens.pdf 5) Ashcroft, R.E. (2005). Standing up for the medical rights of asylum seekers, J Med Ethics 31: 125-6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1734103/pdf/v031p00125.pdf 6) Ku, L. and Matani, S. (2001). Left out: Immigrants' access to health care and insurance, Health Affairs 20(1):247-256. http://old.projectshine.org/files/shared_images/Left_Out.pdf

25 7) Cavallero, E. (2006). An immigration-pressure model of global distributive justice, Politics, Philosophy and Economics 5(1):97-127. http://ppe.sagepub.com/content/5/1/97.abstract 8) Weiner, M. (1996). Ethics, National Sovereignty and the Control of Immigration. International Migration Review, Special Issue: Ethics, Migration, and Global Stewardship 30(1): 171-197. (online)

December 9th: Research Ethics and Course Conclusion

Main points:  How can we protect research participants?  Should all research be allowed? How can we evaluate the costs and benefits?  At what point is placebo-control unethical?  How can we advance ethical research and take into account stakeholders?  Course conclusion

CASE: Developmental Disabilities in Transplantation- Community Ethics Board

Readings: