Latest / Health Ethics Podcast / Universal Healthcare: On Human Dignity, Global Co-Operation, and Financial Sustainability

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Universal Healthcare: On Human Dignity, Global Co-Operation, and Financial Sustainability · Health Ethics Podcast

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Welcome to the COVID Ethics Series podcast, a conversation with leading experts about bioethical
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issues that have been exacerbated due to the COVID nineteen pandemic. I'm Brian Pilkington,
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and I teach bioethics at Seatonhole University and at the Hackensack Marine School of
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Medicine. I moderate the COVID Ethics Series in cooperation with the IHS Library and
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IHS Student Life. This podcast is a spinoff collaboration with the IHS Library where
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we'll have the opportunity to go deep with the experts from our series. Thanks
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for joining our conversation. Welcome everyone to the COVID Ethics Series podcast. I
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am Brian pilkin Ten, your usual host. Thank you for being here with
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us today. I'm especially excited for our conversation with Professor Ruy News of the
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University of Porto. So let me share with everyone a little bit about Professor
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News, and then we'll jump in to talking about his new book, Healthcare
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as a Universal Human Rights, Sustainability and Global Health, which is a wonderful
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read and I think a deep dive into some political philosophy, some bioethics,
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and also medicine. So Professor Ruy Nuns was born in Portou in Portugal and
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European Union. He has a medical degree from the University of Portu as well
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as a PhD in bioethics. He's a full professor of Medical Sociology and Bioethics
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at the Faculty of Medicine at the University of Portu and also the president of
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the Ethics Committee of the faculty. He has also brought this will come up
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in our conversation the International Chair of Bioethics to portug and lead that group.
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So, Professor Nownt, thank you so much for joining me tonight. Thank
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you very much for the invitation. So let's get right into it and talk
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about the book. So, as I mentioned, the book is titled Healthcare
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as a Universal Human Rights, Sustainability and Global Health. Big question is why
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this book, why this topic? Why now? So what is it about
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the current state of health across the globe that motivated you to work on the
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subject. Yes, first of all, let me thank you for this kind
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invitation, Professor Brian Bill Gilden. It is a pleasure being here. Of
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course I met him at the International Chair in Bioetics and I will enjoy very
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much this conversation. Well health is a complex concept. Of course, we
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can have a broad concepts, such as the World Health Organization concept of a
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stake full well being from a physical, mental, psychological, social perspectives.
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We can have also a concept of health more a biomedical one. I'm a
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physician, so I was trained to treat diseases. Nevertheless, whatever the concept
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we adopt, I feel that it is a very important evolution of humanity to
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consider that everyone, everywhere in the world should have the opportunity to develop the
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best health says status he or she can develop. Of course that when we
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are speaking about the right to healthcare access, we could go deeper and stating
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that everyone should enjoy precisely that status a full well being. But I would
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be very pleased if every country in the world could promote and empower and activated
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a healthcare system that leaves no one out. I'm from Portugal European Union.
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Luckily, at European Union, all twenty seven twenty seven member states have very
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comprehensive and well design public health systems. They are not only public, they
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are a mix between public and private systems. But nevertheless, it is very
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important from my point of view, if we agree that healthcare access of appropriate
4:44
quality is a right, fundamental basic right, of course, there are many
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people that would not agree on that. Libertarians, for instance, my dearest
4:55
friend Professor Tristram Mindohart Junior, that came a lot of time here to Porto,
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will not agree on this assumption. But nevertheless, at least in Europe,
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we agree that everyone should have access to an appropriate level of healthcare,
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and in that way, with other health measures and public health measures, of
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course, that each one of us could develop the best state of health that
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it is possible and also that we want to reach, because health is also
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something that relies on our own responsibility. So stating that in Europe we have
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been creating since the beginning of twentieth century, and every country since at least
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the middle of twenty century, namely after World War Two, because as we
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know, World War two was a devastating war and it was important too rapidly
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to provide healthcare to everyone so that Western civilization would develop. And so in
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Europe every country developed a public system that coexists with private provision. But nevertheless,
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the public provision is more or less responsible for sixty five seventy sixty percent.
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It depends on the countries. So that is a strong backbone of a
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public healthcare system that is financed by the taxpayers, so that no one is
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out of the system. What are the advantages for a specific society, name
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the European societies this perspective. First, this is something that is a civilization
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approach approach to development. So we feel that human development, as Martia Sen
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would suggest, is a mix between richness of a country, but also social
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rights like education, like health, like protection of the old age, like
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protection of maternity, illness, et cetera. So that we look at human
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development both from a richness GDP perspective but also from social rights and also a
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human rights approach. So we feel that a modern developed society should regard all
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those components as indispossable for our common development. But it is not only a
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question of principle or of ethics or of rights. It is also a pragmatic
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conclusion that countries, when they have this social background around they are they are
8:03
more inclusive and the inequalities do not evolve to social convulsions. It is very
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interesting because in Europe it has been comproved that one of the reasons why we
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did not have war for seventy years, and the war that we have now
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is precisely in countries that do not feel the same way we do. One
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of the reasons Europe that is probably the part of the world where wars happen
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more consistently. Well, during the last seven years in Western Europe we could
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find this. We could find development and social collision and the welfare state in
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general and healthcare systems in particular are the most important tools to achieve these goals.
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So I would say that to promote welfare state, namely a public healthcare
9:03
system has this dual advantage. First, it is in accordance with our sets,
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principles and beliefs. But also we feel that is the best way to
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promote peace and develop within a country and between countries, and so the European
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Union I feel it is a good example. Moreover, during this terrible pandemic,
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it also also comproved, at least in Europe, that countries that had
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more strong public systems, integrated systems could fight more easily the pandemic. Why
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because there is a coordinated response, an integrated response, And this conclusion I
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think is also a very important one if we look into the future. Of
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course, there are many different ways propelling and empowering public systems. I'm not
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going to discuss that here. Even in Europe we have these marketing systems,
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beveragep type systems, mixed systems. It never mind. What is important is
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this assumption that no one is left behind due to the principles and the ethics
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about it, but also because of the consequences. So a utilitarianist argument could
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also be proposed because society like this is a more cohesive society, and we
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have this very important experience in all European Union countries and that's probably the reason
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why so many other countries from Europe that are not from European Union want to
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get in this common project. Moreover, in the European Union now we speak
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about a European Union for health. So we rely on the public systems or
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mixed systems public and private from each country. But there are some measures that
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this pandemic has very well comproved that cannot be dealt with only by a specific
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country, even rich countries like Germany or Friends, or Italy or the UK.
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Before living the European Union, so we agreed on in Europe, that
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there are some public health measures, some protection for instance of infectious disease,
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getting strategic reserves, pharmaceuticals, etc. There are many measures in healthcare and
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in health in general that should be dealt with in this large economic and social
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space. And it is this kind of example that my book proposes to the
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world, and not only to the European Union. Why first of all,
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because as we all know, there are important issues in health and health care.
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I repeated, no country alone can dealt can deal with even very strong
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and rich countries like the United States or China, or even European Union.
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See for instance, the climate change, see for instance the migration politics,
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see for instance the problem of the warming of the climate and scarcity of resources
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like water. All these issues and I'm not speaking again of pandemics, but
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again also pandemics must have a global approach. So if we want that globalization
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riches its goals and they are not only economic calls. The economic calls of
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globalization are very important, of course they are. They could bring hundreds of
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millions of people, namely in Asia and even in Africa from poverty to middle
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class. So globalization, economic globalization was very important. But to it must
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go to another level, a new age of globalization, not only of economic
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globalization, but also social globalization, meaning that if we do not have this
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perspective, this insight to look at the world and to see that the world
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is development developing in different rhythms, that countries that are not full democracies,
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like in Europe or the United States, or even Brazil and other South American
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countries. If we do not set an example to the rest of the world,
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the world is going to be very different in ten twenty years. So
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we should give the example. And what is the good example from my point
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of view, First of all, to promote some kind of common humanitarianism,
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that is a common view of humanity, respecting fundamental values, fundamental rights like
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the wines in the Universal Declaration of Human Rights, like the ones Unesco Declaration
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of Human Rights, and bioetics, but nevertheless respecting different cultural and perspectives.
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So it is very important that this globalization of Western values respects differences between cultures,
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because we do not want to be new colonialists of ideas. We want
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to promote a message that is the message of boetics and human rights and women's
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human rights, but that they should be then interpreted in different societies and cultures.
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And one of the strongest message that we can pass is Zactually for me,
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it's precisely the message that health that is one of the most basic human
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needs and rights every pool, everywhere in the world. Shows that the major
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concern of people everywhere in the world is concerned by safety and concern by hell.
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So if we could give make some steps to fight poverty. We are
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doing that through economic globalization, but again helping other countries to activate structured and
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financed, well financed healthcare systems. I think it would be a good message,
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and it would be from my point of view. And again we have
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this European experience a very important way of promoting not only health and health care,
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but also democracy and human rights. So my main point is this promoting
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welfare state in accordance with the resources specific society has. It is also a
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way of promoting democracy, full democracies everywhere in the world and the enjoyment of
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human rights. And this book is a modest tool to suggest this path,
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meaning that although health is a very complex concept, but nevertheless we can and
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shoot as vilest other countries with no paternalism to precisely beginning to implement a healthcare
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system that includes everyone, because in the end everyone would be better off,
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the ones that have access to that system and the ones that might have not
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so much access but indirectly benefit from that because they live in a more prosperous
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and more safe society. Levels of safety of a society are also indexed to
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the levels of social protection. It is also a conclusion that we might reach
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from distances. President, thank you so much that you highlighted well and anticipated
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a few of my question. You highlighted really well. What I loved about
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the book and again for folks listening, this is healthcare as a universal human
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rights, sustainability and global health. And what I loved about it was both
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that it's philosophically rich. Right, you go into deep conceptual analysis to support
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your claims about health, but you also have that practical component. So in
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a moment, I want to jump back to your friends you mentioned the late
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Tris Engelhart and maybe ask about some of the potential disagreements there. But first
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I wanted to ask about the concept of dignity, because dignity plays a role
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in the argument throughout the book. It serves as sort of ground for some
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of your arguments in favor of a universal right to healthcare. So for members
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of our audience, for folks from all across the globe who are listening,
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how do you you, sort of briefly, how do you think about dignity
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and how does this connect up to your work on universal human rights? Well,
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it is deeply grounded in human dignity. Well, I'm a physician,
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so I'm I'm acquainted with human suffering, and I'm also a professor of bioetics.
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I did these two pathways in parallel since twenty five years old. And
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I believe from my personal experience but also of course from my readings and from
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my work, that the perfectly not only just society, but developed society,
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in modern society should require regard any one of us have someone that is that
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has an intrinsic value, has a specific dignity in a Cantian perspective, taking
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into account that every whenevers should be regarded as an individual of course with rights
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and with human rights, and should be of course protective in a sense of
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that individuality that is unique and that has a specific value in society. So
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this is a this is a rational perspective not a theological theological one, to
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be clear, I believe and I think it is the common perspective, namely
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of the United Nations, that each one of us, independently of being a
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man or a woman, of the color of the skin, of the of
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the ethnicity, of the religion, of the politics, in the end,
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we are all humans. The pandemic showed that show that very very well,
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that in the end we are all humans. And of course they have there
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should be some kind of ontological solidarity between humans, because we are of course
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individuals and autonomous beings and with free will. But nevertheless we live with other
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people and for other people. So that's the way I look at humanity,
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and that the human being and that human person. I'm a strong defensor of
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the autonomy of the person, namely in healthcare. For many decades I defended
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in Europe and elsewhere in South America the informed consent, living will. Even
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in my country it's about to be approved a law on active euthanasia. So
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we should look at people as full persons, as moral asians, with full
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dignity, with full rights. Of course, any policy of discrimination is regarded
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as an ethical of course, That's why I have proposed some years ago to
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UNISKO a universal Declaration on Gender equality, because I believe that men and women,
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not speaking about the other genders, but namely men and women should have
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not only the same equal opportunity in the beginning, for instance, of access
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into education or to health, but to attain the more develop level of human
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development, of the talents and the capacities that one has, one should have
22:41
the possibility to develop it, to develop that. So I would regard the
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human dignity as the foundational principle of the modern bioetics, and of course every
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other principle would be a development of this concept of human dignity. I know
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that it is not a concept so much approach to a United States. It's
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very common in Europe and countries with European tradition. Of course, it is
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not a concept that is easy to define, but it is something that we
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can feel. We can feel that the human being and the human person is
23:29
entitled to be recognized as an entity with dignity and read respect, and so
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everything flows the adductively of this approach. If I assume that a human being
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is a subject of dignity and the rights, of course, it is very
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easy to construct a fundamental basic right to health care access of appropriate quality with
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a safe assumption on the basis. It is very interesting because in the Portuguese
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Constitution it is a very very well known discussion here in my country. When
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the Law on the Healthcare and Constitution regarding healthcare was approved, the constitutional law
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not totally creates a right to healthcare access, but states that all people in
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Portugal have access to healthcare. For instance, if when of you visit Portugal
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and have a health problem, he or she would be treated exactly as I
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would be, although I am a taxpayer for many years in Portugal, because
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it is regarded as a question of dignity and the human rights. We have
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many immigrants as every country, as from Brazil and other countries, even from
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Ukraine. When they go to the Portuguese nation health service, they would be
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treated exactly as I would be. So because we feel that a modern society
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is an inclusive one. Of course, this has a problem, and the
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problem is the sustainability of the healthcare system. And so in my book I
25:19
also make a suggestion, and it is a suggestion with many years of study
25:25
and many articles published, so it is very well sorted and how can we
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create and activate a public system financed by the taxpayers that is sustainable, in
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accordance with the social contract, in accordance with the amount of resources that the
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taxpayers want to allocate to health so that the level of expense is not so
25:57
high that it is not so sustainable for the future. We believe also that
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it is very important that we take into consideration that speaking of human dignity and
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human rights is not only requisite of the actual generations, but we should all
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have in mind the responsibility to the future generations. We know that this is
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fundamental principle when we are speaking about environmental protection and climate reduction. But we
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speak exactly in the same perspective regarding the sustainability of the welfare state and the
26:44
healthcare system, meaning that we cannot postpone the expenses of healthcare for the future
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generations. We do not have that right. So we must live in accordance
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with our resources. And this is the message. This is probably the more
27:03
important message of my book, is to tell societies that are not so developed
27:10
as the American or the European societies to begin building an integrated and consistent healthcare
27:18
system in accordance with the resources they actually have to allocate to healthcare. So
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I defend a progressive approach, and I give the example of my country.
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When we began, we began late, more like than most European countries building
27:37
the healthcare public system. We began also only in the seventies, in nineteen
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seventy four. Well, the British National Health System service is from ninety forty
27:49
eight. Well, we began thirty years later. But in this moment,
27:55
the Portuguese system is better than the British one according to international and comparisons.
28:02
So no country is condemned to be in a specific level if we take the
28:10
appropriate actions and we learn with the mistakes of others, because of course we
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learn in Portugal with the mistakes of other countries, so that we tried not
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to make those mistakes, we can develop very fast. So this is the
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message. Namely, as you know, Portugal has many countries throughout the world,
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namely in Africa that's speak Portuguese and so perfect, and so we try
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to send this message to build and integrated a comprehensive system step by step in
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the right direction, with the right values and principles, with the right tools.
28:56
For instance, we suggest to implement immediately the rules and principles of modern
29:04
management, what we call in health the new public management. So not going
29:11
to the mistakes we made with the traditional bureaucracy in healthcare, and so to
29:18
implement new modalities of healthcare management that are more efficient and are more in accordance
29:27
with the sustainability of a public healthcare system. It can be done. This
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is the message. It can be done. And again, if we look
29:37
at international comparisons, we see that many countries like the Netherlands, Belgian,
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Scandinavian countries, Australia, New Zealand, and Canada, et cetera, have
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very very good public healthcare systems that are sustainable. They are sustainable. Why
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they are sustainab well because they are well managed quality of management, but also
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because they implement an ethical principle and an ethical perspective that is ethical priorities,
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meaning that in a public system, an open system, due to this broad
30:18
concept of health, it is impossible to give everything to everyone. So we
30:25
should not make this mistake of believing that in a public system, the public
30:30
system has the responsibility to give everything to everyone. No, it has the
30:36
responsibility to give to society what the resources that society has and those resources are
30:48
able to provide for So in my book, I propose a mathematical formula that
30:56
justifies ethically what I just said. A very very developed country like Switzerland,
31:03
for instance, probably will deliver to its citizens more goods in health than a
31:11
less developed country. It is in health like in any other good, in
31:17
public transportation, in safety, et cetera. So we should have this capacity
31:22
to understand that it is ethical, it is acceptable, it is morally acceptable
31:30
that a country that has less resources, although believing that healthcare access is a
31:37
right, should build and empower and provide a system in accordance with the resources
31:47
that country has and with the help of the international community and with the development
31:52
of that country. That's why I asked for a new wave of globalization.
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I feel that every country in the world will have the possibility of having also
32:07
a good healthcare system in the world. It is a question of political will
32:13
and wisdom of society. So society civil society is very important because, as
32:21
we know, the political political will and the political political decision makers follow the
32:30
trends. They want to be responsive responsiveness. They won't be responsive to the
32:36
needs and the will of that society. So it is also very very important,
32:40
and I speak of that in my book, that the levels of health
32:45
literacy and levels of health education are higher in all societies. And the pandemic
32:53
of the COVID nineteen just shows us that it is very important that the citizens
33:00
are right, that full citizens responsible citizens. And to be a full responsible
33:07
citizen, I must be aware of the common problems of health, of public
33:12
healths of healthcare, success of the measures that I can make for myself to
33:19
reach a higher state of health. Professor, that that's ononderful. The I
33:25
mean rooting your work in dignity, I mean it's a little bit of preaching
33:31
in the choir music to my ears, and I my experience is very similar
33:37
to yours. In lecturing in the US on this concept, I often reference
33:43
your work, reference the work of the United Nations because it's more of a
33:46
global concept. Maybe I think there's growing interest in the US, but I
33:52
see how the focus on the individual and also sort of the broad global community.
33:58
Your call for increas global why dignity is a very nice basis as sort
34:02
of the foundational principle, And I love the way you said that of bioethics.
34:06
And then the other kinds of principles sort of come from that. You
34:10
might have already answered this, so I'll let you just sort of put a
34:13
finer point on it. But I was taken by your discussion of a global
34:19
ethical conscience, and I think as you were just sort of framing the last
34:22
bits of your answer to Dignity, you're getting close to what you say in
34:24
the book about this global ethical conscience. So I just wanted to invite you
34:29
to say a little bit more, especially for students, bioethics students, medical
34:35
students, health science students, nursing students in the US where I teach,
34:38
because we often talk about what might be owed to sort of broader community.
34:44
So if you could say a bit more directed a bit towards that audience about
34:49
your take on the global ethical conscience, that would be very welcome. Well,
34:54
I think that we are now facing a very detive moment. Although everything
35:02
I wrote in my book is previous to this disruptive moment. I wrote the
35:08
book previously or during the pandemic, and surely before the war in Europe.
35:17
But we also we all feel that the world is changing so and very rapidly.
35:27
So what are the solutions what are the solutions. I'm a physician.
35:31
I must get solutions to problems. I should, and I try to reflect
35:37
on those problems, to speculate on them, to read many authors. But
35:43
in the end we should promote solutions to complex problems and phenomena. And as
35:51
far as I see it, I think we are now at the crossroads and
35:57
the only way we can uh reach a level of global development. And the
36:06
true piece and harmony between all peoples is that it is only if we can
36:14
provide skeleton of development, full human development that is ethically superior to other models.
36:25
And I think that both we in Europe and you at the United States,
36:34
and even in South America, et cetera. So modern democracies, democracies
36:40
not only have this possibility, but have this responsibility. And I believe much
36:47
more in the power of words, of thinking, of arguments than any other
36:55
power, the power of weapons, or the power of any It is a
37:00
transient power. I think that the true power is the power of ideas and
37:07
of ideals. I usually say that ideals are the true viruses, much more
37:15
strong than the COVID nineteen because they entered people's minds and they do not live.
37:23
So I think that especially the ones of us that devoted our lives to
37:30
bioetics, I have even more this responsibility because if we are able to propose
37:42
a pattern, a model of society, as I said before, respecting the
37:52
particularities of which culture, which culture, but nevertheless having here a minimum minimum
38:01
human itearimis a minimum global conscience. I think that step by step also societists
38:12
will go in this way and will naturally converge. They will not be forced
38:17
to converge, they will naturally converge. See for example, what is happening
38:24
in Central Europe right now, where a creating is naturally in the gravity of
38:32
this perspective human development. It is not a question of language or religion.
38:38
Whatever is a model a human and a pattern of human developed. So I
38:44
think that if we in bioetics can have this capacity to promote without imposing any
38:52
values or principles, but only exposing those values and discussing them, I think
39:00
that step by step those values, this we will will be able to construct
39:12
exactly that global conscience and the global humanitarianism that it is not a political one.
39:21
I feel it is very important that organizations such as the United Nations,
39:27
such as UNIS call unis et cetera exists, of course, but I think
39:32
that the next level will be reached by a more active citizenship, global citizenship.
39:43
That's my belief. We could see that, for instance, with the
39:46
problems that a couple of years ago happened in South America in Amazonia. As
39:53
you know, Amazonia is responsible for the largest part of the reinforest in the
40:02
world, and so when something happens there, it is a world problem.
40:07
Well it is. It was very interesting to see, at least in Europe,
40:12
the mobilization of the civil society of the answers protecting namely Brazilian Amazonia.
40:22
So just to say that we we should take into account and take advantage,
40:31
for instance, of the digital transition of this new technologies of communication in the
40:37
future into the artificial intelligence and the punic computing, et cetera, all both
40:44
modern tools to interact freely and responsibly, so that we can discuss these values
40:55
with this openness and and this free, free freedom that we are doing right
41:01
now, so that we can reach everywhere in the world. And I'm sure
41:09
that everyone that is rational, everyone that knows how to read them to write,
41:17
will will be not only able but interested in learning more and engaging in
41:24
this common perspective of humanity. So I feel that we in bioetics have this
41:35
huge responsibility because we know the principles, we know the theory, we we
41:43
deal with this every day, so we are the perfectations to develop this kind
41:51
of new new world. Just to give you an example, in my own
41:57
city, in Porto, Portugal, I ran during six years a program in
42:02
every school of the city. Well, the city is not so large,
42:08
but it has more or less three hundred thousand people. But nevertheless, in
42:14
every single school I ran a program that is bioetics in school and it was
42:20
an amazing program because children, namely fourteen fifteen years old, learned bioetics with
42:30
a speed that my own medical students did not were not able to do.
42:37
So I think that through education, an open education, an education that is
42:46
open to all, not trying to indoctrinate anyone, but only to expose.
42:53
I think that we could do that and can do that in our own societies
43:00
and at the global level. And I think that in this way it will
43:05
be more easy therefore, and in consequence, to implement human rights in general
43:10
and social rights like the right to healthcare access. Thank you Professor another really
43:19
helpful answer, and I see the clock that we're running out of time.
43:23
There's so many questions. I mean, the develop the discussion of a global
43:29
ethical conscience, rooting it in the programs you've run in Porto in the schools,
43:34
so I think connects up nicely to some other work that you've done on
43:37
the notion of refined conscience. I mean, there's so much we could talk
43:39
about, and we still haven't gotten to the sort of debate with Professor Engelhart,
43:45
but we'll have to save that for another time. So I want to
43:47
thank you. This has been enlightening for everyone listening. I'm speaking very much.
43:53
Yes, thank you, thank you. I'm speaking with Professor Ruy Nunes.
43:57
Please we'll have it on the website. Check out healthcare as a universal
44:00
human rights, sustainability and global health. And i'd also encourage everyone to look
44:07
at the work that professor is doing as at the International Chair in Bioethics.
44:15
So again, professor, thank you very much. It was wonderful to see
44:17
you again and hopefully we can speak again soon. Thank you very much for
44:22
follow you. Thank you for listening to this episode of the COVID Ethics series
44:28
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