Julio Torres, Intern
George J. Annas is William Fairfield Warren Professor at Boston University, Chair of the Department of Health Law, Bioethics and Human Rights at Boston University School of Public Health, and professor in the Boston University School of Law. In his book, Worst Case Bioethics: Death, Disaster and Public Health, Annas explores how fear of worst case scenarios impacts bioethics through examples ranging from healthcare to bioterror. In the excerpt bellow, Annas dissects the former by means of analyzing metaphors and how they inform and impact the American healthcare phenomenon.
The first thing most Americans think about healthcare is not death and disaster. We’re good at denial. Nonetheless, the fragmented non-system we use for healthcare is based primarily on responding to the life-threatening risks of death. It is focused on saving lives and curing or stabilizing diseases, and only secondarily on disease prevention or improving quality of life. Nor is it not just death prevention at the end of life; death, in the form of risks, underlies medicine from the point of view of both patients and physicians from the moment of birth, even from the moment of conception. Death is personal; disasters affect populations. It is not uncommon to portray American healthcare itself as a disaster. At least since World War II, we have sought to reform a system that is itself widely viewed in disaster imagery, perhaps the most popular being that out healthcare system is a “train wreck.”
A good example is President Lyndon Johnson’s response to what he described as the “bombshell” Medical proposal to go along with his proposed Medicare plan. He explained his support for both proposals to Wilbur Cohen, the person who would take the lead in drafting them (with Wilber Mills) for his administration. He told Cohen the story about the railroad giving an intelligence test for switchmen. The question was:
“What would you do if a train was coming east going sixty miles per hour, and you looked over your shoulder and another one was coming the west going sixty miles an hour?” …and the fellow said, “I’d go get my brother.” And he said, “Why would you get your brother?” And he said “Because he hasn’t ever seen a train wreck.”
The image of a train wreck can be used to mobilize action, but train wreck imagery can be overwhelmed by other metaphors mobilized to resist reform. As I write this chapter, the House and Senate have each reported bills out of committee, but have yet to debate them. President Obama is committed to increasing health insurance access for Americans, but the longer he and his allies delay endorsing a specific plan, the less likely its success becomes, because financial stakeholders in present system will have time to find ways to frustrate meaningful reform.
Lawrence Brown has suggested that the metaphor blocking health reform to date is the “safety net,” which includes emergency departments and community health centers, because this imaginary net is seen as protecting even the uninsured from major health disaster. Similarly, William Sage has observed that we have yet to identify a health systems metaphor with traction. Metaphors referencing two struggling American industries, automobiles (“So you want Chevrolet or Cadillac coverage?”) and airlines (as a metaphor for patient safety), have, for example, failed to capture the public’s imagination.
Shortly after the demise of President Bill Clinton’s healthcare plan, I suggested that both the military and the market metaphors in American medicine had become counterproductive, and that they should be replaced by the ecological metaphor. This has not happened (at least not yet), and the Obama administration has continued to cling to the mast of the Clinton’s 1993-94 framing of the healthcare financing reform debate as shipwreck again threatens us. Of course, it is not just a replacement metaphor we need, but one that can help us confront and modify the major characteristics of American healthcare.
The inspiration for American healthcare is perhaps best embodied in Damien Hirst’s 2007 diamond-encrusted platinum human skull. The skull was cast from that of an 18th-century man; the original teeth are retained and the skull is coated with 8,600 diamonds. Hirst calls the diamond skull “For the Love of God” and says he was inspired by similarly jeweled Aztec skulls. As a metaphor, the skull displays all four of what I take to be the most enduring and problematic characteristics of American healthcare (and that of America itself): it was wasteful, technologically driven, individualistic, and death-denying. Nonetheless, skulls are not inspirational, even diamond frosted one, and this one has a strange allure that may subvert rather than promote reform. We need a plan more than we need a metaphor, but a plan without a metaphor is unlikely to be politically (or even economically) viable. What should it be?