Patricia Illingworth

Bluffing, Puffing and Spinning in Managed-Care Organizations

I argue that because bluffing, puffing, and spinning are features of corporate life, they are likely to characterize the doctor-patient relationship in managed care medicine. I show that managed-care organizations (MCOs) and the physicians who contract with them make liberal use of puffing and spinning. In this way, they create a context in which it is likely that patients will also use deceptive mechanisms. Unfortunately, patients risk their health when they deceive their doctors. Using the warranty theory of truth I argue that although bluffing may be ethical in business because all participants agree to it and business has not warranted truth-telling, it is not ethical in a medical context because physicians and MCOs have warranted truth-telling and the quality of medical care depends on it.

Solidarity for Global Health

This paper introduces a special issue of the journal Bioethics devoted to the exploration of the role of solidarity in health. Papers in the special issue include Solidarity in Contemporary Bioethics – Towards a New Approach by Barbara Prainsack and Alena Buyx; A Dialectic of Cooperation and Competition: Solidarity and Universal Health Care Provision by Samuel Butler; Family Solidarity and Informal Care: The Case of Care for People with Dementia by Ruud ter Meulen and Katherine Wright; Solidarity, Children and Research by Barry Lyons; Altruism or Solidarity? The Motives for Organ Donation and Two Proposals by Ben Saunders; and Global Solidarity, Migration and Global Health Inequality by Lisa Eckenwiler, Christine Straehle, and Ryoa Chung. After reviewing the included papers, the introduction highlights the critical issues that remain if solidarity is to provide a viable normative principle for the distribution of health resources and the analysis of a wide range of bioethical problems. The introduction points in particular to solidarity’s association with partiality as especially problematic, and asks whether solidarity can maintain its forcefulness and efficacy as a guiding principle in a global context if it were stripped of its partiality. Without answering the questions, the introduction presents the special issue as a forum for its illumination.

THE ETHICAL IMPLICATIONS OF THE SOCIAL DETERMINANTS OF HEALTH: A GLOBAL RENAISSANCE FOR BIOETHICS

In this special issue, Bioethics explores the ethical issues that relate to the social determinants of health. As the articles demonstrate, the recognition that social factors help to determine a population’s health offers bioethics new challenges and new opportunities. With this recognition, fundamental bioethical concepts, such as causation, autonomy, rights, and justice, take on new meanings. Likewise, mainstay bioethical issues, including the equitable distribution of resources, the duties of professionals, and the conflict between paternalism and autonomy, become amenable to new perspectives. The realization that social forces help to determine health is hardly new. For millennia people have recognized a relationship between the social environment and disease. In the 19th century, sanitarians blamed the rampant filth of growing cities for the incessant outbreaks of disease. Later progressive reformers lambasted both poverty and poor working conditions for disease and premature death. The pioneers of epidemiology documented these relationships. The field of bioethics has never been closed to such concerns. Since its inception in the 1960s and 1970s, however, bioethics has deployed much of its intellectual energy on the moral issues that relate to the development, distribution, and delivery of health care services. In so doing, the field reflected medicine’s eclipse of public health in the 20th century. As medicine became predominant and illness became more and more amenable to individualized medical treatment, ethical discourse came to emphasize clinical encounters. At the same time, as disease and health increasingly came to be seen as resulting from individual factors, individuals began to be viewed as morally culpable for both their illnesses and the impact of those illnesses on others. Not surprisingly, given the importance that bioethics placed upon individual patients and providers, autonomy surfaced as a key concern. In the early years bioethicists focused on the autonomy of patients. Following the lead of John Stuart Mill, bioethicists revealed the dangers of medical paternalism and explained why and how patient autonomy should be respected. In this they were highly successful, as informed consent became both widely regarded and legally established. Individual autonomy remained of paramount interest in the 1990s. By then, however, the concern widened to include the autonomy of physicians. At least within the USA, physicians criticized managed care for interfering with their ability to make decisions for their patients and infringing upon their professional autonomy. And throughout the developed world, as health care costs rose, market solutions were debated. Patients began to be viewed as ‘consumers’ of medical care instead of as patients in need of treatment and care. Not surprisingly, once patients were seen as consumers responsible for selecting their own healthcare in market transactions, some ethicists were apt to disavow physicians’ fiduciary duties. Caveat emptor replaced the duty of beneficence as the invisible hand of the market was viewed as the source of just outcomes. Frequently neglected in mainstream bioethical discourse of this era – although well noted by bioethicists working from feminist and communitarian traditions – was the fact that individuals are never simply self-determined but are selves nestled in relationships with other individuals, communities, and the wider world. This neglect is vanishing. With globalization and the rise of pandemics including, HIV/AIDS, and new global threats, such as global warming, the deep connections between individuals, communities, and the wider world can no longer be overlooked. Moreover, although many empirical questions remain unanswered, voluminous research has now firmly demonstrated the existence of significant disparities in health between the rich and poor, across the globe and within nations. As the World Health Organization’s Commission on Social Determinants of Health recently stated: ‘These inequities in health, avoidable health inequalities, arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces.’ In response, bioethics must expand its horizons and consider the ethical issues that arise from the social forces that help to determine health, as well as the ethical problems that result from interventions that target those forces.

With a Little Help from the Law

We can do a lot to create and protect social capital. Treating social capital as a moral principle will do an enormous amount to override our inclination toward self-interest, address the free-rider problem that exists with some social capital and, in the end, build our social capital reservoir. The moral requirement to act impartially will counter the tendency toward homophily, diminish social capital’s dark side and contribute substantially to our reservoir of global social capital. But we can also use the law to bolster social capital. Doing so would constitute more than a mere nudge, since the penalties associated with violating the law would reduce people’s options. Nonetheless, given the value of social capital and the harms associated with its deprivation, we need to take seriously the potential role that law can play in creating and preserving social capital. In this chapter and the next, I look at the impact of the law on social capital. Law affects trust, generalized reciprocity and social capital. It can do so either positively or negatively.

The Moral Sweet Spot

Social capital seems to make people happy. Because of this, it can be important for utilitarian ethics. In this chapter, I describe some of the social science findings with respect to social capital, happiness and well-being. For these purposes, the terms happiness and well-being are used interchangeably. Subjective well-being refers to a person’s own appraisal of their happiness and well-being. It turns out that social relations are important, not only because people are happier when they have good, meaningful ties with others, but also because of the phenomenon of emotional contagion. Happiness spreads through social networks; so too for other emotions such as depression. Social capital may be the moral sweet spot, an effective mechanism for maximizing happiness, overriding self-interest and overcoming homophily — social capital’s dark side.

The Ethics of Us

Communities are cohesive, generous and safe when social capital is available. Children do well in school and on standardized tests. People are healthier when there is adequate social capital. Despite these benefits, the persistent need for it and worldwide deprivation, social capital may not blossom fully. Because some social capital has public good characteristics, it can suffer from a free-rider problem. In a society governed by individualism and self-interest, the non-excludability of social capital (its rainmaker effect) can discourage people from acting in ways that would build social capital reservoirs. If people don’t have a way to exclude others from benefitting from the fruit of their activities, and they are motivated primarily by self-interest, they may be unwilling to contribute to the social capital reservoir. Indeed, even if people are not motivated by self-interest, if they live in a society in which the prominent norm is self-interest, they may not want others to free-ride on their contributions. Although social capital may be the proverbial win-win, those under the spell of self-interest may not view win-win scenarios as worthwhile.

The Heart of the Matter

Before turning to the main argument of this book, it will help to have a good understanding of what social capital is and what it brings with it. This is easier said than done. There is no single definition of social capital. Deservedly, it has been the subject of study by researchers and practitioners from a variety of fields, each with their own focus. Although traditionally a political, sociological and economic concept, more recently social capital has been the focus of the field of public health. It has also been embraced by government, practitioners in management and development. In the first half of 2011, the Organization for Economic Cooperation and Development (OECD) included social connections and civic engagement — both associated with social capital — among the key indicators of well-being for people living in developed economies and some emerging economies. For the World Bank, “social capital is a concept that has significant implications for enhancing the quality, effectiveness and sustainability of World Bank operations, particularly those that are based on community action.”1