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Editor of New Philosopher Zan Boag interviews Hilde Lindemann, Professor of Philosophy at Michigan State University and the former editor of Hypatia.
Zan Boag: What responsibility does a society have for the health of its individuals? Where do individual responsibility and societal responsibility begin and end?
Hilde Lindemann: Health depends on a number of factors, and access to healthcare is only one of them. Good societies provide a decent minimum of healthcare to everyone, including non-citizens, but they also provide things like plumbing, clean water, housing for the homeless, adequate food, health and safety regulations for workplaces, and so on. Interestingly enough, it’s been shown that in countries where the gap between rich and poor is relatively small, no matter how poor the country is overall, health outcomes are better for everyone – even for the rich. And higher levels of education are also correlated with better health, so if societies provided access to a solid education for everyone, individuals’ health would improve. It turns out that the best way to keep poor women from having babies they don’t want and can’t afford is also to educate them, so education has that benefit as well. Of course, access to contraception is also a social responsibility that promotes women’s health. And gun control has been and remains a public health responsibility that Americans keep shirking. Certainly individuals are also responsible for their own health, although there’s no bright line between social and individual responsibility, as so many things individuals are responsible for – such as exercise and a sensible diet – can be next to impossible for some people. I’m thinking, for example, of the so-called food deserts that are found in inner cities and rural areas, where there are no supermarkets but only little convenience stores that sell mostly unhealthy foods to people who have no means of transportation. It’s pretty hard for women in particular to exercise if it’s not safe to be out on the streets alone in their part of town. And the problem of obesity is not primarily something individuals are responsible for either, if you live in a society where you must drive a car to work and then work long hours at a desk, and you haven’t got enough time to cook nutritious meals on a daily basis, so you rely on fast food and take-outs. Th e health of indigenous peoples is a fraught one for Australia, New Zealand, and Canada, as well as for the US, not only because these people have been and still are denied access to many of the goods on off er in our societies, but because they’ve lost their cultural heritage – as have the blacks in the US, whose ancestors were forced to leave their homes in chains. Th ese things cause ill health, and for that there is more than enough societal responsibility to go around.
ZB: What makes a society healthy?
HL: I think individual and social responsibility are so tightly enmeshed with each other… Obviously, environmental pollutants have taken a tremendous toll on individual health. Toxins that enter the water table through run-off from industrial farming, acid rain, chemical dumps, oil spills, lead paint, asbestos, and emissions from carbon-based fuels, are not good for people’s health. In that sense, I suppose you could say that a society rife with such pollutants is an unhealthy society, where ‘health’ refers to the health of the individuals who make up the society. But, as I pointed out earlier, many social factors cause poor health, including a wide gap between rich and poor, inadequate education, limited access to fresh water, and all the rest. It’s important to bear in mind, I think, that ‘healthy’ is often used as a normative term, where it really means ‘passes moral muster’. In that sense, people talk of a healthy economy, healthy race relations, healthy democracy. But I think it’s probably better to say ‘good’ when we mean ‘good’ and reserve ‘healthy’ to refer to individuals’ good physical functioning.
ZB: Eric Fromm claims in The Sane Society that a society can be sick. Casting a glance around at the mental and physical health of some in Western society, it would be hard to argue otherwise. In which areas is our society in need of treatment?
HL: Well, we’re speaking metaphorically here, but it’s pretty clear that the way we treat our children is unhealthy. If you look at a country like France, where there is abundant paid parental leave when a child is born and good, government-subsidised day care, children fl ourish. According to a new study from UNICEF, in the US nearly a third of children live in poverty. Or, you could put it this way: my country ranks 36th out of the 41 developed nations included in the UNICEF report. That’s 24.2 million children and the number is increasing annually. Poverty is very bad for children’s health, not only because these kids go hungry and get ill from living in substandard housing, but because their schools are unequipped to provide even the most basic education. And as everyone knows, the rate at which we incarcerate young people in the US, especially for non-violent crimes, is higher than anywhere else in the world. That too strikes me as terribly unhealthy, as is our relative lack of social security for the poor and our unwillingness to convert from fossil fuels to clean energy. Tying health benefits to jobs, as we do in the US, has been particularly hard on women, who are more likely than men to curtail employment or forego it altogether so that they can take care of their young children or chronically ill family members. It’s also hard on the working poor, who might be working three jobs but none of them with health insurance benefits, so that any serious illness drives them further into poverty.
ZB: Pharmaceutical and medical companies would have us believe that the answer to better mental and physical health lies in more drugs, more treatment, more procedures. Apart from the environmental effect of the drugs, chemicals and byproducts entering the biosphere, what other ethical issues do we face in this Age of Pharmaceuticals?
HL: One big problem is how these drugs are tested. To receive FDA approval for marketing them, they have to pass an ethical review by an IRB, but often these IRBs are not independent assessors – they work for the drug company. So there’s a huge conflict of interest there. And when a drug goes off patent, so that generic versions can legally be manufactured, companies sometimes make a very slight alteration to the formula of the drug and test that, so they can market the new drug as a variant under the same brand name. Often the test subjects are homeless people or people so poor they need the money to live on, and they aren’t always cared for properly. Another problem is that in the US, where insurance companies decide what can be covered and what can’t, insurance won’t pay for talk therapy, because it takes longer and is labour intensive, so patients aren’t necessarily given the best care. And a third problem is that when the old mental hospitals were emptied in the early 1970s, patients were meant to be cared for through community mental health centers, but these were inadequately funded, which means patients can have great difficulty getting access to the help they need. And a fourth problem has to do with drug addiction. Many rehab centres won’t accept pregnant addicts, and one of the consequences has been that black women in particular have been turned over to the legal authorities and end up in prison instead of getting help for themselves and their babies. There have been reports of such women giving birth manacled and in chains, and then arrested for delivering illegal drugs to their babies via the umbilical cord. All of that has got to stop.
ZB: Let’s say that medical science all of a sudden makes a breakthrough: the key to eternal youth is discovered and we can now live forever. What ethical issues would we face? What of future generations?
HL: Some philosophers who have written about this (I’m thinking especially of Thomas Nagel) argue that death is the greatest harm that can befall anyone, because it’s the end of all the goods of action and experience. He might embrace immortality. Others of us would not, seeing death as a part of life and believing that everything, including human life, should come to a fitting end. As I age, I fi nd that I can no longer keep up with the zeitgeist as well as I could when I was in my forties – I don’t follow the music or other parts of youth culture as I once did, and I think that’s OK. I think I’d get tired of life, that I could outlive myself, and I like the idea that there is a rhythm to life that we all participate in. Premature death is a tragedy, but I don’t think death at the end of a normal human life span should be met with anger and indignation. We humans can only take in so much, and in due season it will be time for us all to leave. In Atul Gawande’s new book, Being Mortal, he says that doctors, including himself, have been wrong about what the physician’s role is. Rather than doing everything in their power to cure their patients and stave off death until there is nothing left that they can do, he argues that doctors should help their patients accept the cycle of life and work to help them live as well as they can until it is time for them to die. It’s a view that has been reiterated in the medical and bioethics literature for over thirty years, but the medical profession seems to need to hear it repeatedly. Overtreatment at the end of life is a real problem, brought about partly because doctors have not been well trained Being mortal in the care of the dying and partly because specialists aren’t thinking about the patient as a person so much as they are trying to restore function to the particular organ or system they specialise in. As long as doctors think of death as a personal defeat, I’m afraid Gawande’s message isn’t going to get the uptake it deserves.
ZB: One last question: what can we do to contribute to a healthy society?
HL: We can vote! We need political leaders who will work to prevent climate change, keep guns from proliferating in our society, house the homeless, care for children, close the divide between rich and poor, provide more resources for education, give us economic policies that actually generate better jobs for more people, close prisons until the only people left in them are those who pose a danger to others. As a professor, I can teach my students to think critically and well about social factors that bring about poor health and how to improve them, and I can do my part not to pressure my doctors into giving me diagnoses that won’t affect treatment, or treatments that are unduly expensive. I can accept that I will die one day and not resist it at all costs. And I can volunteer my time and talents, doing my share to make my society a good one for those who come after me.
Hilde Lindemann is Professor of Philosophy at Michigan State University. The former editor of Hypatia, her ongoing research interests include feminist bioethics and the ethics of families.