Blanket Bans in the NHS: Utilitarian Justice or Unfair Discrimination

       Post-Brexit healthcare from the UK’s National Health Service (NHS) has been under continuous burden as a nearly exponential demand in patients and a diminishing supply of resources persists. In the midst of consistent pressure to deliver quality care with limited funding and lingering debt from previous overspending, the NHS has not set national standards for reform. Just recently, and nearly two months post-Brexit, The Guardian covered a shocking decision made by a local, clinical commissioning group (CCG) within the broader NHS system to alleviate healthcare pressure using a blanket ban. From this point forward, all clinically obese persons, individuals with a BMI of 30 or over, will be denied elective surgeries for up to one year in the Vale of York CCG (1).

Does this decision exercise appropriate principles of justice in biomedical ethics? Furthermore, what are the consequences of these measures? One result is clear - the decision did not come without criticism. President of the Royal College of Surgeons (RCS), Dr. Clare Marx, heavily denounced the Vale of York’s action as one of the most precarious decisions made in the present-day NHS (1). Dr. Marx further stated that the RCS is not only in support of aiding clinically obese patients in their desire for speedy medical interventions, but also that “[delaying] patients’ access to what can be life-changing surgery for up to a year is wrong” (1). One NHS bariatric surgeon, Dr. Shaw Somers, described the Vale of York’s denial of elective surgery to clinically obese persons “like discriminating [against] a segment of the population on the basis of their colour or religious persuasion,” markedly because obesity is a medical illness (1).

           Despite clear contentions, the Vale of York stood by its decision. The CCG argued that its recent mandate was necessary for optimal healthcare services given the stringent availability of resources (1). The NHS maintains the decision because the CCG is still within its legal right to pursue such an approach. While the NHS emphasized that further review should be taken, an NHS spokesperson did advocate for the possible outcomes of the CCG’s move: “Reducing obesity and cutting smoking not only benefits patients but saves the NHS and taxpayers millions of pounds” (1). In the end, the driving factor for the Vale of York is to distribute the maximum amount of services for as many patients as possible within their limited capacity.

    Yet, will the end justify the means? According to Tom Beauchamp and James Childress’ Principles of Biomedical Ethics, conflicts in distributive justice and allocation of goods and services in times of scarcity is a healthcare issue that has transcended all generations and borders (2). Moreover, inequalities in healthcare access raise important questions about the justice of decisions made by policymakers for the public good. In the case of the Vale of York’s decision to deny elective surgeries to clinically obese persons, a strong utilitarian theory of justice was applied by the CCG. Beauchamp and Childress highlight the definition and purpose of utilitarian justice as a means to maximize net social utility and form healthcare policies that are based on cost-benefit or risk-benefit analysis (2).

    Utilitarian justice has major advantages for the Vale of York CCG in a post-Brexit NHS. One idea that utilitarian justice might not consider, however, is the fair-opportunity rule of Rawlsian theory. As an example of egalitarian thinking, the fair-opportunity rule stresses that individuals should not be denied social benefits because of undeserved, disadvantageous conditions for which they have no control (2). An enlightening view of this theory offered by Beauchamp and Childress says that the intrinsic properties given to individuals by the social and biological “lottery” of life cannot be discriminated against in “social allocations if people do not have a fair chance to acquire or overcome these properties” (2).

           Since obesity is a medical illness, which is linked to a myriad of genetic, environmental, economic, and societal influences, should the fair-opportunity rule not apply to the decision made by the Vale of York (3)? If the answer were yes, then the connection between denying clinically obese persons standard access to elective surgeries based on the condition of their illness would classify as an unfair discrimination. Some might argue that without a strong utilitarian mode of justice, then the already limited NHS resources and funding would plummet.

    In response, I pose another scenario in which other CCG’s across the NHS uphold decisions to deny access the healthcare options to clinically obese persons. When access to healthcare becomes increasingly scarce for those populations of patients, is the interest of the common good truly being served to its maximum capacity? If we allow blanket bans to prevent or give lower priority healthcare access to those with intrinsic, disadvantageous conditions for which they have no control, then who will face unfair discrimination next?   

References:  

1.   Beauchamp, Tom L., & Childress, James F. (2009). Principles of Biomedical Ethics. New York, NY: Oxford University Press.

2.   Rawlinson, Kevin, and Chris Johnson. (2016, Sept. 3). Decision to deny surgery to obese patients is like 'racial discrimination'. The Guardian.  Retrieved from https://www.theguardian.com/society/2016/sep/03/hospitals-to-cut-costs-by-denying-surgery-to-smokers-and-the-obese

3.   Why People Become Overweight. Harvard Health Publications. Retrieved from http://www.health.harvard.edu/staying-healthy/why-people-become-overweight  

Eight African, Asian nations at risk for Zika outbreak

A new study jointly funded by the CDC and the Canadian Institutes of Health Research identified eight African and Asian nations that are at the greatest risk for experiencing outbreaks of the Zika virus in coming months. Using three different modeled scenarios, including one mirroring the spread of the comparable Dengue virus, researchers labeled India, China, the Philippines, Indonesia, Nigeria, Vietnam, Pakistan and Bangladesh as the countries most at risk (Sun 2016). The combined population of the affected areas is over 2.6 billion, and nearly 400,000 travellers visit the identified risk areas annually (Bogoch et al. 2016). The identified nations have warm, humid climates and are considered resource-limited and the populations immunologically naive, presenting a vulnerable breeding-ground for the Aedes aegypti mosquito and the Zika virus that it can carry. Some scientists hope that prior exposure to Zika in African and Asian nations, where outbreaks of the virus have previously occurred, will confer immunity to some members of the population.

References:

Sun, Lena H. "Zika Outbreaks Most Likely to Hit Eight Countries in Asia, Africa." Washington Post. September 2, 2016. Accessed September 10, 2016. https://www.washingtonpost.com/news/to-your-health/wp/2016/09/01/zika-outbreaks-most-likely-to-hit-these-countries-in-asia-africa/.

Bogoch, Isaac I., Oliver J. Brady, Moritz U G Kraemer, Matthew German, Maria I. Creatore, Shannon Brent, Alexander G. Watts, Simon I. Hay, Manisha A. Kulkarni, John S. Brownstein, and Kamran Khan. "Potential for Zika Virus Introduction and Transmission in Resource-limited Countries in Africa and the Asia-Pacific Region: A Modelling Study." The Lancet Infectious Diseases, September 1, 2016. doi:10.1016/s1473-3099(16)30270-5.

Chinese dog meat trade fetches international opposition

    Throughout July, animal advocates achieved a few minor victories in the greater struggle against the Chinese dog meat trade. Over 1,400 dogs were spared from slaughter at the eleventh hour in the first few rescues coordinated by China Animal Protection Power (CAPP), a Humane Society International (HSI) task force (Humane Society International, 2016, July 1).

    Members of CAPP, a dog welfare advocacy group under the direction of HSI, spotted the dogs in trucks bound for slaughterhouses in the Yunnan province of southwest China. Activists intercepted the trucks and, with the aid of local authorities, engaged the drivers in rescue efforts lasting up to 50 hours. Although desperately needed food, water, and shade were provided to the dehydrated and exhausted dogs, at least 30 dogs did not survive this final leg of their inhumane treatment. The surviving dogs will receive veterinary care and proper treatment until they are healthy enough to be placed for adoption, thanks to funding by HSI (Humane Society International, 2016, July 1).

    These were the first efforts by the HSI task force which was established in late June by Humane Society International following the annual Yulin Dog Meat Trade Festival. Opposition to the festival, which is responsible for the annual slaughter of up to 10,000 dogs, has been the impetus for HSI’s growing anti-dog meat trade efforts (Humane Society International, 2016, June 20). The rescues are just one part of a multi-faceted campaign by HSI to abolish the dog meat trade across China and eventually Asia (Humane Society International, 2016).

    According to Humane Society’s Wayne Nacelle, the festival “is a terrifying and intense reminder of the horrors of the Chinese dog meat trade” (2016). In the past 6 years, 10,000 dogs are reported to have been slaughtered annually for the event; a mere fraction of the estimated 30 million dogs murdered in slaughterhouses per year around Asia. According to the World Health Organization, the dog meat trade “spreads rabies and increases the risk of cholera 20-fold,” due to the unhygienic conditions imposed on the dogs, both before and after their slaughter. Yulin did not have a historical industry for mass dog slaughter or consumption, until the festival’s 2010 creation by dog traders to improve profits (Humane Society International, 2016, June 20).

    Outcry against the festival has been international in scope, taking form as celebrity opposition, the introduction of a congressional resolution, and a world-wide supported petition. In the United States, outspoken celebrities including Ricky Gervais and Simon Cowell, have launched protests and social media campaigns against the dog meat festival (Humane Society International, 2016, July 1). On the governmental level, American citizens are sending a message to the Chinese government through a congressional resolution, communicating the lack of acceptance of dog as food in the Western world. Wayne Pacelle from the Humane Society states that,

The resolution, which has 27 original cosponsors, doesn’t have the force of law, but it’s an opportunity for the United States to urge the government of China and Yulin authorities to protect against pet dogs being stolen and sold into the meat trade. It calls for a ban on the killing and eating of dogs and urges China to enact an anti-animal cruelty law banning the dog meat trade” (2016).

Another major impact was made with the joint-petition by HSI, Beijing Mothers Against Cruelty, and Vshine, signed by 11 million people against the infamous dog meat festival (Denyer and Ginglu, 2016).

    Although clearly prevalent, the consumption of dog meat is not widespread in Chinese culture. According to Chinese polling company Horizon, the majority, 69.5 percent, of Chinese citizens have never eaten dog meat (Humane Society International, 2016, June 20). The practice is argued by Lu, Bayne, and Wang (2013) to have its roots in the resourcefulness of Chinese peasants during times of poverty. Proponents of dog meat consumption claim the traditional Chinese practice is thousands of years old and attribute to it a variety of health benefits. Although the consumption of “novel foods” including dogs, cats, bugs, and sharks fins, is a fad in relatively advanced Chinese cities, the Horizon poll reports that 51.7 percent of Chinese citizens support a complete ban on the dog meat trade. While opposition to institutional violence against dogs grows in China, advocacy by local groups has increased overall, often concentrating efforts on well-publicized events such as the notorious Yulin Dog Meat Festival.

    Many animal advocacy groups in China originated following the introduction of a translated copy of Peter Singer’s Animal Liberation in the 1990’s. However, the belief in animal rights is neither novel nor solely Western, as the Chinese Animal Protection Network points out, claiming “the three pillars of Chinese tradition, Buddhism, Taoism and Confucianism, all have teachings regarding respect toward the lives of animals — they are the essence of animal rights.” (Lu, Bayne, and Wang, 2013). Nevertheless, upset revolving the dog meat trade and the festival is invariably led by “Younger generations of Chinese, who are becoming more urban and adopting a culture of pet care and companionship” (Humane Society International, 2016, July 1).

    While the abolition of the Chinese dog meat trade is sure to be a victory for animal advocates worldwide and is imperative to obtaining justice for dogs, the success confers serious implications. On its most fundamental level, the concept of animal rights implies equality in the consideration of all animals. In light of the predominating pet culture in the Western world, renouncing the inhumane treatment of dogs while perpetuating that of animals deemed “fit for consumption” invariably widens the gap within speciesism, an obvious contradiction to the goal of advancing animal rights.

References:

Denyer, S., & Ginglu, J. (2016, June 10). Activists gather 11 million signatures against China’s infamous dog-meat festival. The Washington Post. Retrieved August 3, 2016, from https://www.washingtonpost.com/news/worldviews/wp/2016/06/10/china-stop-eating-dogs-animal-rights-activists-campaign-against-annual-festival-of-slaughter/#comments

Humane Society International. (2016, June 20). 20 dogs rescued from slaughter just one day ahead of China's Yulin dog meat festival, photos [Press release]. Hsi.org. Retrieved August 3, 2016, from http://www.hsi.org/news/press_releases/2016/06/yulin-rescue-20-dogs-062016.html

Humane Society International. (2016, July 1). Chinese Activists Rescue 400 Dogs Bound for Meat Trade Slaughter in 50-Hour Standoff [Press release]. hsi.org. Retrieved August 1, 2016, from http://www.hsi.org/news/press_releases/2015/06/kunming-dog-meat-truck-rescue-070115.html

Lu, J., Bayne, K., & Wang, J. (2013). Current status of animal welfare and animal rights in China. ATLA, 41, 351-357.

Pacelle, W. (2016, May 25). Dog butchering raising howls in Congress and throughout the world [Web log post]. Retrieved August 3, 2016, from http://blog.humanesociety.org/wayne/2016/05/congressional-resolution-condemns-yulin-dog-meat-festival.html

AIDS 2016

What if I told you I was a citizen?
A citizen of a universe
A universe like no other
No other place could match it
Match its harmony and freedom
Freedom of speech, sexual orientation and status
Status of being HIV positive or negative,
Black or white, gay, straight or bisexual
Male, female or transgender

What if I told you how life changing it was
It was a hub of information, truth and dreams
Dreams of reaching 90-90-90 goals
Goals where we want to end HIV/AIDS as a pandemic by 2030
2030 – 2016 equals 14 years of dedication
Dedication to advocacy, activism, relentless volunteerism, access
Access to reproductive health commodities, to medication

What if I told you that I was in a room full of people?
People whose passion for fighting this war against HIV/AIDS is unmatched
We matched, yes we did, screaming ‘Sex work is work’
F Word
Proclaiming ‘Treat All’
H Word
Everybody is got a right to be who they are
And yes we said everybody who walks through those doors is entitled to treatment!

I mean all we do is debase each other
I see all we do is discriminate against each other
I’m whisper ‘NO NO NO, lets love each other’
To my colleague, sharing these chairs with one another
On stage Elton John preaching ‘Let’s come together’
Our Benoni girl pleading ‘let’s not have another’
Coz we already had the other
Twice, SA host International AIDS conference

What if I told you I’m still a citizen of that universe?
And that I am of the generation
That will end HIV/AIDS

Kidney racket in India uncovered

Indian police have uncovered a group trafficking human kidneys in a prominent private hospital in Delhi. Ten arrests have been made so far, including two surgeons’ assistants and the ringleader of the organization. The group “has been operating for the last one-and-a-half years in Delhi and Kolkata” (McKirdy and Pokharel, 2016). Poor people were lured from all over India to give up their kidneys for a small fee. The suspects then sold the organs for up to $7,500 (BBC News, 2016). According to Mandeep Randhawa, the Deputy Commissioner of Police of Southeast Delhi, it is unknown exactly how many kidneys were traded and how much money changed hands, although the police have been able to confirm five cases occurring in a period of four to five months (McKirdy and Pokharel, 2016).

Apollo Hospital, where the trafficking allegedly took place, denies any involvement in the operation. A hospital spokesperson described Apollo as “a victim of a well-orchestrated operation to cheat patients and the hospital” (BBC News, 2016). Nonetheless, police are investigating transplant committee members at the hospital “as all institutions in India are required to have a committee approve kidney transplants” (McKirdy and Pokharel, 2016). The hospital suggests that forged documents were used to pass stringent procedures. The hospital has given their full cooperation to the police as they continue in their investigation, and police are also monitoring other hospitals in the area.

McKirdy, E. and Pokharel, S. (2016, June 6). Delhi hospital kidney scam: 5 arrested. CNN. Retrieved from http://www.cnn.com/2016/06/05/asia/india-delhi-hospital-kidney-racket/index.html

McKirdy, E. and Pokharel, S. (2016, June 9). Delhi hospital kidney scam: Ringleader nabbed. CNN. Retrieved 9 June 2016, from http://www.cnn.com/2016/06/09/asia/india-delhi-hospital-kidney-racket/

Kidney racket at top Delhi hospital - BBC News. (2016, June 4). BBC News. Retrieved 9 June 2016, from http://www.bbc.com/news/world-asia-india-36452439