I am writing my student fellowship paper under the broad topic of health worker “brain drain,” so I have been keeping an eye out for related news stories. Two stories that caught my eye in the past few weeks were about the health worker migration from civil war torn Syria and economic-crisis ridden Sudan. In Syria for example, half the doctors in Homs and all of the country’s nine psychiatrists have recently migrated. In Sudan, 1620 doctors left the country last year compared to 338 in 2008. In countries like these, especially Syria where medical personnel have been targets of violence, solutions to stem the migration or replenish the ranks seem particularly futile. Additionally, these countries’ self-inflicted wounds, including civil wars and poor administration, complicate matters. Not only do these internal struggles diminish the probable efficacy of potential solutions to the brain drain, but they also negate the perceived responsibility of the countries receiving these migrants, diminishing their will to help counteract the deleterious effects of the brain drain.
Civil war stricken countries like Syria present especially difficult cases for developed nation responsibility and intervention. But these news stories led me to think about brain drain and responsibility that results from war, specifically wars waged by developed nations in developing ones. A prime example is the recent war in Iraq. The Brookings Institute estimates that 20,000 of the 34,000 Iraqi doctors in the country in 2003 have migrated, and only 1525 had returned as of 2009. They also cite that 2000 Iraqi physicians have been murdered and 250 have been kidnapped over the same period. 50% of surveyed Iraqi doctors living both in Iraq and abroad said they had been threatened. A recent article in Lancet describes that before 2003 the major problems facing the Iraqi healthcare system stemmed from drug shortages and poverty. These problems have been superseded by violence and failing infrastructure in the intervening years. The brain drain has likely been exacerbated by these new threats.
[Disclaimer: I am not involved in this, and the views expressed here are entirely my own.]
Concussions and Performance Enhancing Drugs (PEDs) have been the dominant subject of concern in the sports world recently, and for good reason, but I would like to highlight an often overlooked and more general problem. Our athletes are rewarded for pushing their bodies to the brink to accomplish majestic feats, requiring physical perfection. We laud playing through injuries to succeed at the pinnacle of sport, or recovering from injuries at super human speeds, only to return those bodies to the brutal punishment of competition. With these pressures, Concussions and PEDs can be viewed as mere symptoms of a culture that runs from the fans to the teams to the players themselves, asking them to sacrifice their bodies, sometimes, to the detriment of their long-term health. In this new age of awareness about player health, we should be asking: Are athletes making properly informed rational choices about their health? Or are there situations where neither the players nor their teams are properly incentivized to protect long-term player health due to the culture described above?
Some recent stories have exemplified the culture:
In Part I, I described my testicular cancer diagnosis and pre-operation experience in an attempt to demonstrate how defragmentation in healthcare could reduce patient emotional and psychological stress. In Part II, I describe my post-surgery experience, consulting specialists with conflicting opinions as to the optimal post-operation treatment regimen.
In various law school courses we discuss a problem sometimes referred to as the “battle of the experts.” In a courtroom, a jury generally hears testimony from experts on both sides of a case, presenting different statistics and opinions for the jury to consider. The jury, comprised of lay people, is likely ill-equipped to contextualize these opinions scientifically, and possibly resorts to heuristics, such as judging the experts’ levels of confidence, demeanors and comprehensibility, when deciding between them. A nuanced testimony delivered by a sweaty expert, when compared to a simple testimony delivered suavely, could be discredited for legally irrelevant reasons. As a patient weighing my post-surgery treatment options, I felt like a lay jury, asked to decide among the opinions of experts, with my own health hanging in the balance.
This past September, I had the unfortunate and ironic experience of transitioning from conducting research on the American healthcare system to being a patient in the American healthcare system. In September, I was diagnosed with testicular cancer, while working as a research assistant for Professor Einer Elhauge, scouring the Affordable Care Act for regulatory powers with potential for defragmenting our national healthcare system.
Professor Elhauge, recently described fragmentation as a systemic lack of coordination between physicians, as well as between physicians and hospitals. This fragmentation results in increased medical cost and medical errors. My experience as a patient has led me to believe that defragmentation could help reduce other, less quantifiable, emotional and psychological costs to patients. I will attempt to demonstrate this through recounting the first half of my story.
In Glenn Cohen’s first post on this blog, he questioned whether Mitt Romney’s position on abortion was coherent with respect to the rape and incest exception, but did not question the self-defense exception itself. He addressed the self-defense exception briefly: “Through the well-known doctrine of self-defense, the criminal law has long recognized that an individual may be justified in killing to protect his or her own life, or possibly health, and these exceptions merely reflect a similar view as to fetuses.” He is correct to say that this is the established position, one that dates at least as far back as the Talmud. But, assuming one believes that the fetus is a person entitled to the full panoply of rights, is the self-defense exception defensible?
Lethal self-defense is generally legally justified when used to protect your life. This is even true in cases where the attacker is not morally culpable. Judith Jarvis Thompson, in her article entitled “Self Defense,” argues that this is true because they will “otherwise violate your rights that they not kill you.” She then extends the rights of self-defense to third parties arguing that the rights are not personal (agent-relative).
Additionally, in the article “A Defense of Abortion,” Judith Jarvis Thompson argues forcefully against the position that abortion should be impermissible even when the mother’s life is at risk. This position is untenable from the perspective of the mother because “[i]t cannot seriously be said that . . . that she must sit passively by and wait for her death.” In the abortion case, it follows that a third party (doctor) has the right to save the mother’s life as well. I find this to be a convincing argument against the position that abortion should never be allowed. But does it establish that every time the health of the mother is at risk she has the right to abort the fetus, killing a person?