Lawrence J. Schneiderman, M.D, is Professor Emeritus at UCSD Medical School and Visiting Scholar in the Program in Medicine and Human Values at the California Pacific Medical Center in San Francisco. His new book, Embracing Our Mortality: Hard Choices in an Age of Medical Miracles, looks at end of life decisions from both the medical and philosophical perspectives and advises on how to best make tough decisions. In the article below Schneiderman questions how our health care system can be reformed.
Despite overwhelming evidence that single payer universal health care is more economical, acceptable and effective than all the alternatives, our politicians and policy makers quarrel without letup over the alternatives. Who should be the major payer? The federal government? State governments? Should large corporations be required to offer health insurance? What about small businesses? How much should be the responsibility of individuals and how should the tab be presented–via tax credits, payroll deductions, cash co-pays? Mandatory or voluntary? And so on and so on.
In other words, Washingtonian powers are preoccupied with how to pay for health care. Hardly any thought is given to what should be paid for-as though health care is a commodity that needs no examination with regard to what health outcomes should be achieved.
We can see the results–inconsistent, even incoherent rules, regulations and statutes that squeeze and contort the flow of health care dollars, and, not surprisingly, squeeze and contort the quality and distribution of health care services. Some Americans, some of the time, are covered by health insurance policies, some of them useful, some of them not. A large and growing number of others-now up to forty-seven million-are not covered at all. They can only envy the puzzling assortment of citizens in special categories whose health care coverage is guaranteed, including members of the military and veterans (okay), the over sixty-five (oh well), people with kidney failure (why just them?), members of Congress (huh?), and prisoners (are you kidding!).
Why have these gated communities have been constructed? For one simple reason: to control costs.
Are politicians and policy makers right to be transfixed by the inevitability of out-of-control costs under a universal system? Not if we accept a simple ethical stricture with regard to health care: In a just society everyone is not entitled to everything. Everyone is entitled to what the philosopher Norman Daniels calls a fair opportunity, namely a “decent minimum” level of health care.
What is a decent minimum? In my opinion, it is a level of health care that enables a person to acquire an education, hold a job, and raise a family. Or, if the person is unable to meet these goals, to attain a reasonable level of function within the person’s limits, as well as a reasonable level of comfort, whether it be from pain or other forms of suffering.
This definition accomplishes two things. It recognizes the importance of each person, not in isolation, but in relationship to other members of a just society. And it assures that society’s need for productive citizenry is recognized as a practical trade-off for the burden of health care costs all of us in that society have assumed.
Let’s consider diabetes mellitus–a common disease with life-threatening yet potentially preventable consequences.
A decent minimum level of health care would start with guaranteed prenatal care to give the developing fetus and newborn the best chance for a healthy beginning, and continue with ongoing nutritional and life-style counseling to reduce risk factors such as obesity.
If, despite these preventive measures, the person developed clinical diabetes he or she would receive guaranteed coverage for chronic disease management, including optimal glucose control by diet and medication, along with education and monitoring to prevent infections and organ damage.
As long as the person was gaining an education, holding a job or raising a family the decent minimum would include any and all necessary high-tech life-sustaining interventions, including renal dialysis, and organ transplantation.
Later in life, when the person was no longer pursuing those goals, the emphasis on decent minimum medical care would shift from high-tech life-sustaining interventions toward treatments that provide a reasonable level of function within the person’s limits, as well as a reasonable level of comfort, whether it be from pain or other forms of suffering.
At this point you might say-Wait, isn’t this the United States of America? What about our hallowed respect for freedom of choice? Suppose someone wants more than the decent minimum treatment and is willing to pay for it-and it is not medically futile. My answer would be: We should permit it. Won’t there be different levels of health care if we allow this? Yes. Isn’t this unethical? In my view, no. For the simple reason that if all citizens have at least sufficient health care, a decent minimum that enables them to participate in society, then inequalities can be ethically justified for those who wish to obtain more expensive and elaborate health care on their own, as long as their privilege does not deny others of their rights.
This, I propose, is the American way to health care reform-a communitarian approach that is consistent with our capitalistic traditions and supplies what is missing today in the endless debates promoting one or another gimmick to control health care costs.