Tag: Ethics

Pharmacy Benefit Managers

Pharmacy Benefit Managers – Another Shadow Healthcare Actor

Posted on by jabittan
Unless you are a health policy person, I’m guessing you have not heard of pharmacy benefit managers, or PBMs. The Commonwealth Fund describes a PBM as “a company that manages prescription drug benefits on behalf of health insurers, Medicare Part D, large employers and other payers … by negotiating with drug manufacturers and pharmacies to control drug spending.” I always thought that pharmacy prices were set directly by my insurance carrier, in contracts that they had worked out somewhere along the line. But it turns out it is more complicated than that, and if you are like me, you will probably understand that PBMs provide some value, but also feel as though they are another actor doing little but driving the cost of healthcare up. For me, it is probably a bit unreasonable, but I hate PBMs.

 

In his book The Opioid Crisis Wake-Up Call, Dave Chase explains how pharmacy benefit managers negotiate rebates with drug companies and insurance carriers for specific drugs. However, the rebates don’t actually get back to the patients. Usually the insurance carrier and PBM are the ones who benefit from the rebate, and specific medications are pushed toward patients so the PBM and insurer can get the rebate. PBMs operate way in the back, and don’t get the same scrutiny as health insurance companies. They are hidden and shielded from risk, which means they have little incentive to put patients first.

 

“PBMs are typically paid by the transaction or employee; it’s not their money, so its not their risk,” writes Chase. “They may strive to handle claims quickly and efficiently, but their defenses against fraud and abuse of prescription drugs are antiquated. The shared responsibilities of the employer or government agency and the PBM create situations in which neither can see the whole picture. Criminals exploit this weakness, leading to a flood of prescription opioids on the street. The American insurance system has allowed this distribution explosion to occur, doing little to nothing to halt its growth.“

 

The quote above highlights the misaligned incentives with PBMs, insurers, and governments or employers. PBMs that hide data, favor medications for unclear reasons, and don’t face a lot of direct risk have created lots of problems for the American healthcare system. I opened with a discussion of pricing problems brought on by PBMs, and Chase’s quote shows how they have also contributed to the abuse of prescription opioids. Chase’s book, with examples like the ones laid out in this post, paints a worrying picture of pharmacy benefit managers in the United States. It is partly the complexity they add in the system, and partly the shady behind the scenes deals they are a part of that make me dislike them so much. This type of confusing and apparently unethical role for PBMs is also part of the reason that a lot of people want a universal healthcare system that is able to negotiate drug prices and set specific limits on some costs. It might not save everyone a ton of money in the long run, but it might be more ethical and clarify some of the most confusing parts of the system.

An Ethical Dilemma

Posted on by jabittan
In The Elephant in the Brain authors Kevin Simler and Robin Hanson consider human ethics in a framework laid out by Peter Singer. Singer suggested that if we saw someone dying right in front of us, we would have a moral obligation (in instances that did not put us in moral danger ourselves) to try to assist them, even if it came at an expense to ourselves. A common example is that you are wearing brand new very expensive clothing and see someone dying in a situation where you could save them without risk to yourself, but in a way that would certainly ruin your brand new clothes. The loss of our expensive new clothes is almost certainly not a reason to put off helping the person dying in front of us.

 

The question becomes, are we obligated to help people who are not dying in front of us at the expense of the cost of the brand new clothes that we would sacrifice if the person were dying in front of us? Are we obligated to save a life thousands of miles away in a different country and culture for the price of some goods that we might frivolously buy for ourselves?

 

Simler and Hanson lay out this argument in their book and write, “What Singer has highlighted with this argument is nothing more than simple, everyday human hypocrisy – the gap between our stated ideals (wanting to help those who need it most) and our actual behavior (spending money on ourselves). By doing this, he’s hoping to change his readers’ minds about what’s considered ethical behavior. In other words, he’s trying to moralize.”

 

In their book, the authors use the argument of singer and the fact that many of us do not sacrifice the money we would otherwise spend on meaningless things to save the lives of children across the globe as evidence for the elephant in the brain. We say things and signal things that we don’t follow through on, and we are strategically ignorant of the fact that we ignore these aspects of who we are. The authors don’t attempt to criticize us for this behavior, but instead make an effort to point it out and acknowledge that it is a huge driver of human behavior.

 

“Our goal, in contrast,” Write Simler and Hanson, “is simply to investigate what makes human beings tick. But we still find it useful to document this kind of hypocrisy, if only to call attention to the elephant. In particular, what we’ll see in this chapter is that even when we’re trying to be charitable, we betray some of our uglier, less altruistic motives.” Very often we do not escape our own self-interest completely, even when we are doing charitable things for other people. Our ethics and moral philosophies can be trampled by our self-interest, and with our big brains we are able to justify our selfish behaviors.

An Ethical Dilemma

Posted on by jabittan
In The Elephant in the Brain authors Kevin Simler and Robin Hanson consider human ethics in a framework laid out by Peter Singer. Singer suggested that if we saw someone dying right in front of us, we would have a moral obligation (in instances that did not put us in mortal danger ourselves) to try to assist them, even if it came at an high cost to ourselves. A common example is that you are wearing brand new very expensive clothing and see someone dying in a situation where you could save them without risk to yourself, but in a way that would certainly ruin your new clothes. The loss of our expensive clothing is almost certainly not a reason to put off helping the person dying in front of us.

 

The question becomes, are we obligated to help people who are not dying in front of us at the the cost of the brand new clothes that we would sacrifice if the person were dying in front of us? Are we obligated to save a life thousands of miles away in a different country and culture for the price of some goods that we might frivolously buy for ourselves?

 

Simler and Hanson lay out this argument in their book and write, “What Singer has highlighted with this argument is nothing more than simple, everyday human hypocrisy – the gap between our stated ideals (wanting to help those who need it most) and our actual behavior (spending money on ourselves). By doing this, he’s hoping to change his readers’ minds about what’s considered ethical behavior. In other words, he’s trying to moralize.”

 

In their book, the authors use the argument of singer and the fact that many of us do not sacrifice the money we would otherwise spend on meaningless things to save the lives of children across the globe as evidence for the elephant in the brain. We say things and signal things that we don’t follow through with, and we are strategically ignorant of the fact that we ignore these aspects of who we are. The authors don’t attempt to criticize us for this behavior, but instead make an effort to point it out and acknowledge that it is a huge driver of human behavior.

 

“Our goal, in contrast,” Write Simler and Hanson, “is simply to investigate what makes human beings tick. But we still find it useful to document this kind of hypocrisy, if only to call attention to the elephant. In particular, what we’ll see in this chapter is that even when we’re trying to be charitable, we betray some of our uglier, less altruistic motives.” Very often we do not escape our own self-interest completely, even when we are doing charitable things for other people. Our ethics and moral philosophies can be trampled by our self-interest, and with our big brains we are able to justify our selfish behaviors.

An Idea of Inner Moral Views

Posted on by jabittan
In Letters From a Stoic, Seneca writes, “The Supreme Good calls for no practical aids from outside; it is developed at home, and arises entirely within itself. If the good seeks any portion of itself from without, it begins to be subject to the play of fortune.”

 

Seneca seems to be suggesting that we can turn inward and recognize a sort of moral philosophy entirely introspectively. What is good and what we should do can be reasoned on our own, without requiring the input of other people and society. Individually, Seneca suggests, moral ethics, values, and a good life are possible.

 

The views that Seneca puts forward remind me an idea I have had for a while. The idea is that we should individually live in a way that embraces free will. We should live as though what we are going to do will shape the world in a meaningful way and deliver us to the future we want. But when we look at society, we should approach others as if they do not have free will and are limited by their experiences and surroundings in what they can truly accomplish. This pushes us to do our best and achieve great things, but without putting us in a place where we feel better than others and where we don’t put people down because they did not manage to achieve the same level of success as us. In a similar way, we should live our lives believing that we can develop our independent moral values and structures and be a good person without relying on others to tell us we are good, but when we look out at society we should try to work with other people to develop a clear definition and picture of what we think is good, moral, and just. We should view society as operating as though each person is dependent on others and incapable of individually changing the world without collective action. I’m still working through these two contradictory views of self versus world, and while they conflict, they seem to be able to create a narrative that is functional for us.

 

I feel that Seneca’s quote argues for deontological ethics, the idea that we have a duty to do things that are good entirely on their own. I usually take a more teleological view of ethics, which can be defined more as a form of ends justify the means type ethics. I see a deontological view of ethics as being easier to stand on its own without need of justification where teleological ethics is more utilitarian and consequentialist, holding that are actions cannot be deemed to be good solely based on whether we feel they are right, but are tied in some way to the fortune of the outcome that they produce.

 

Perhaps we should live as though our moral philosophy is deontological, telling ourselves that we are going to adopt a set of beliefs and habits that are morally good on their own, simply for their own sake. But we should in reality be living a more teleologial life. We should think about the consequences of going to the gym, of being nice to others, and of making smart donations to Givewell.org recommended charities. We can put on a deontological face, but be almost entirely teleological behind the mask, doing the best to maximize the good we actually achieve while telling others that we engage in good actions simply because the actions are good all on their own. This is again the kind of contradictory split I mentioned above, viewing how we should act in one light, and viewing the way we think about society in an entirely different light. I know it doesn’t make sense to combine and put together into a larger view, but for me it does create a situation where my thoughts and actions align in a way that makes me more empathetic to society and more responsible for my own decisions.

A Theory of Others

Posted on by jabittan
How much do we value other people, and how much should we value other people? At the core of ethics lies this question, and philosopher Peter Singer addresses it in his book The Most Good You Can Do. Singer refers to Canadian philosopher Richard Keshen’s ideas to build his vision of what ethics look like in an age of reason and tackles questions of how we should think about other people. In his book Singer writes, “At the core of the reasonable person’s ethical life, according to Keshen, is a recognition that others are like us and therefore, in some sense, their lives and their well-being matter as much as our own.”

 

This piece of advice is very similar to the Golden Rule, but with one notable distinction. The Golden Rule puts us at the center, focusing on how we want to be treated, and then expanding outward. Singer’s foundation for an ethical person starts with other people and a recognition that the lives of others are just as important in the world as our own life. It builds on common humanity and pushes past areas where see human ethics frequently fall short such as, tribalism, merit, and perceived responsibility. If we cannot start from a place where we accept that other people’s lives are as valuable as our own, we cannot move forward with truly equitable ethical foundations.

 

Singer’s ethical base also reminds me of childhood developmental studies and Theory of Mind, which focuses on a young child’s early recognition that other children and people have thoughts and feelings. This recognition builds until we are able to perceive, predict, and interpret the thoughts, feelings, and ideas of others. From our own consciousness we can begin approaching other people as if they are rational conscious individuals just like us, even though we can never see their consciousness or prove that they have thoughts just like we do. Ultimately, Theory of Mind, a recognition of conscious thought in other people (often also projected onto other living and even inanimate objects around us) begins to shape the ethical foundation of our life.

 

This seems to be built into Singer’s worldview through recognition and reflection of life and consciousness. On a recent episode of Sam Harris’s podcast, Waking Up, guest Yuval Noah Harari discussed Rousseau who said, “I think, therefore I am,” but he was critical of Rousseau’s fictitious “I,” or the self  created by Rousseau out of nowhere and built on in story. Harari explained that the conclusion Rousseau should have reached is simply, “Thought exists, therefore thought exists.” This view does not diminish the reality of our consciousness, but helps us understand that the “I” discussed by Rousseau is simply the story that thought creates. We know that thought exists so it is not unreasonable to believe that others can think, and if others think and can build their own story to create a fictional “I,” then Singer’s ethical foundation still exists and is perhaps bolstered as we recognize the stories we tell ourselves and  as we accept that our thought is in no way fundamentally different from the conscious thought of others which gives rise to our imaginary “I.” Ultimately, we must realize that we are limited in how we experience the world and that others experience the world in the same way. Increasing our ability to think of others and interpret the stories they create for themselves helps us to further our ethical thinking and behavior.

Reasonable Decisions

Posted on by jabittan
I am a public administration student at the University of Nevada, Reno, and what my studies this semester have taught me is that there is no true way to separate politics from policy and administration. The way in which we govern, the bureaucrats that we ask or need to govern, and the decisions that are made will always be political because it is not possible to take self-interest out of the decision making process. We can be technical and rational in our approaches to a problem or in our implementation of policy, but ultimately the direction and base of our decision making is a value judgement. Rational thinking can establish the best means by which we can accomplish something but the ends are always value judgements that we make.

 

With that in mind, we can use empirical evidence to shape our decision making and we can base our ultimate goals on evidence and research, but we should recognize that the goals we set are ultimately shaped by value judgements, even if they are reasonable value judgements. This is where Peter Singer’s book, The Most Good You Can Do, comes in. Singer is a professor of bioethics at Princeton University, and his recent book focuses on effective altruism and how to live a life that is more impactful and like the title suggests, provides the most good to humanity.

 

At one point in his book, which I read well before my venture into a public administration masters program, he focuses on moral decision making from the point of reason. In synthesizing other philosophers he writes,

 

“A reasonable person seeks to hold beliefs that are in accord with the relevant evidence and values that are not open to reasonable criticism by others. … Sound ethical decisions as those that others cannot reasonably reject. Granted, all this leaves open what values are reasonable, but at a minimum reasonable values are values that are not influenced by biased thinking and hence can be defended to others.”

 

Values and moral judgement can flow from rational thought as an individual expands their perspective and synthesizes more information. Self reflection and moral considerations can help an individual develop a worldview where their ethical frameworks are shaped not by emotion but by empirical evidence and rational thought. We can develop strong arguments that the moral and ethical world views created in this manner support the ultimate well being of all humanity, but first we must establish what we will use as our measure, and in his book Singer suggests that we use suffering as our measuring stick. The more our actions reduce suffering across the globe, the more our actions are in line with rational values that can be empirically measured and rationally defended.

 

Where I see an ultimate breakdown is that the ultimate decision, that humans should act to reduce all suffering on the planet, is still a value judgement. It is one that can be reached through rational thought and relative to other goals can be defended through reason, but it is still a value judgement that we put forward. I agree with Singer and find his arguments for effective altruism incredibly motivational, but I think we must accept that our rational thought process is only establishing rational means to achieve a value based end, and we should develop a more open and honest forum for discussing the ends that we aim for.

Expectations and Boundaries

Posted on by jabittan
Fred Kiel addresses the importance of leaders and how they transmit their values and beliefs throughout their leadership teams in his book Return on Character.  He explains that it is important for leaders to hold strong moral values and principles, but he also explains the importance of leaders sharing those values and building them into the ethos of a company in a way that is clear and concise, and easy to connect with for everyone in the company.

 

Kiel explains the importance of leaders being able to clearly communicate their values and expectations in the following quote, “While most people are well intentioned, they also need to have clarity about expectations and boundaries.  If a leader claims that “integrity is the cornerstone of our culture” but fails to spell out exactly what that means in practice, then the claim has little weight or purpose.” What this shows that we must take lofty ideas and connect them back to the basic and every day actions of those within our teams.  Connecting the core values back to the basic process of every employee becomes vital so that the culture and the key values that the leader wants to develop within an organization can manifest in everything that a team does.  Having a leader who can demonstrate how those core values relate fit in with the business can help an organization in a trickle down manner.  The CEO can build those values into the decisions and actions of his leadership team, who can distill those values in practical manners to management levels throughout the company, and those team managers can build those values into the actions of those who they guide and work with.

 

While explaining this process Kiel admits that rules and core values do not fit nicely into a black and white dichotomy, but that there are wide gray areas. He argues that developing character throughout the company will help leaders make decisions that better align with the core values of the company when situations fall within these gray areas.  Having leadership and management teams that display character habits that are in line with the companies core values can help everyone from the CEO to the newest employee understand what is expected and how to act in a way that bolsters the company’s core values as opposed to feigning to adhere to company values.

Minimal Ethics

Posted on by jabittan
In his book, The Most Good You Can Do, Peter Singer discusses living a life driven by moral excellence. The secular philosopher builds on the idea of moral good based on our ability to reason and the faculties of mind which allow us to rationalize society and measure the positivity we add to the universe.  Singer explains that we can be very ethical in our approach to life, mostly ethical, or somewhat ethical in our actions without truly pausing to consider our ethics and our actions or decisions.  Throughout his book he contends that we can begin to understand just how ethical we truly are if we can honestly evaluate our actions through self awareness and through the difficult process of quantifying and measuring the benefits of our actions.

 

Singer writes, “Living a minimally acceptable ethical life involves using a substantial part of our spare resources to make the world a better place. Living a fully ethical life involves doing the most good we can.” In this sense Singer is approaching the world with the view that a minimalist lifestyle should be promoted if we want to do the most good possible with the time and resources we have available to us.  We should look for areas where we have surplus, and find ways to share those surpluses with people who are not as fortunate.  However, he would advocate that we find the most effective use of those resources to make the biggest possible impact with them.

 

Throughout The Most Good You Can Do Singer explains that simply directing spare resources toward charities and the disadvantaged does not reach the most people and provide the most good. Finding an area where your extra resource will go the furthest and provide the most for those who are in need is what Singer argues should be the main goal of an effective altruist (his term for the most ethical individuals). An example from the book of an area where an effective altruist can have the greatest impact is in developing countries in Africa and other tropical regions. The greatest thing that can be done to prevent unnecessary deaths in these countries is the provision of bed nets for a greater portion of the population.  A single bed net can save a life for roughly $100, and it is hard to find another form of charitable giving or donation that can have as great an impact for as little of a cost.  Singer presents multiple examples of powerful uses of extra resources throughout his book.

 

He also addresses areas of confusion and misrepresentation in ethical behaviors and actions.  Singer contends that making donations impulsively, in situations where donations are being asked for in front of grocery stores or after tragic events, does not do as much good as we tell ourselves. According to Singer donations during these moments may be beneficial and help those involved, but we do not donate in these situations to be altruistic. The donations we make in these situations serve more to a help us avoid feelings of guilt, and we should never consider our own guilt when considering charitable donations.