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Connecting

AMERICAN
Values with
HEALTH
Reform
A Publication of
The Hastings Center

3 The Hastings Center


About The Hastings Center
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Connecting American Values with Health


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CONTENTS

VALUES: The Beating Heart of Health Reform • Thomas H. Murray / ii


A Letter from New Jersey Governor Jon S. Corzine / iv

LIBERTY: Free and Equal • Bruce Jennings / 1

JUSTICE AND FAIRNESS: Mandating Universal Participation • Paul T. Menzel / 4

RESPONSIBILITY: Shane and Joe • Jim Sabin / 7

SOLIDARITY: Unfashionable, But Still American • William M. Sage / 10

MEDICAL PROGRESS: Unintended Consequences • Daniel Callahan / 13

PRIVACY: Rethinking Health Information Technology and Informed Consent •


Lawrence O. Gostin / 15

PHYSICIAN INTEGRITY: Why It Is Inviolable • Edmund D. Pellegrino / 18

QUALITY: Where It Came From and Why It Matters • Frank Davidoff / 21

EFFICIENCY: Getting Clear on Our Goals • Marc J. Roberts / 24

HEALTH: The Value at Stake • Erika Blacksher / 27

STEWARDSHIP: What Kind of Society Do We Want? • Len M. Nichols / 30


With liberty and justice for all.
—The Pledge of Allegiance

Values
The Beating Heart of Health Reform

THOMAS H. MURRAY

T
he atmosphere was tense. Representatives of the adamantly insisted, universal access would be the death
insurance industry were huddled in one corner. of the industry. Finally, we understood what frightened
The other members of the Task Force on Genet- them: to insurers, universal access meant that people
ic Information and Insurance, mostly academics and could sail along without any insurance coverage until the
consumer representatives, were bunched across the day they became ill, when they could march into the in-
room. As chair of the task force, I was in the middle, try- surer’s offices and demand to be covered.
ing to make sense of the disagreement, which was grow- That’s not what we had in mind, we explained. Every-
ing more intense by the minute. one should have to pay their fair share and, when they
Our mandate was to provide recommendations about needed care, their health insurance would be there to
what health insurers should and should not do with ge- cover the cost. We described it as universal participation.
netic information. This was the early 1990s; there wasn’t Fine, said the insurers, we can agree with that.
much information available about an individual’s genes, Among the lessons I learned from chairing the task
but the avalanche of genetic information was gathering force (including: Don’t fly from England to San Francis-
strength. The first few pebbles had arrived recently, and co and expect to control a contentious meeting), one
ever larger ones, such as the tests for genes linked to stands out for this collection of provocative essays: un-
breast and ovarian cancer, would appear soon. We had derstanding what’s at stake in a public policy debate is as
time—not a lot, but some—to plan for how private vital as it can be elusive.
health insurers would deal with information about our Connecting American Values with Health Reform is our
genetic risks for diseases, from the rare and inexorable effort to identify what is at stake amidst the swirling con-
progression of Huntington’s disease to far more common fusion of proposals for delivery systems, financing, cost
ones such as Parkinson’s, diabetes, and heart disease. control, and other details necessary for any practical re-
Health insurers were accustomed to shaping policies ac- form. These details, though, are instruments carrying
cording to the risks people presented. If someone with with them the impedimenta of history, habit, and inter-
cancer was like a house afire, someone with a genetic risk ests. To see things afresh, it helps to return to founda-
of cancer was a house with a smoldering pile of rags in tional questions: What do we want health reform to ac-
the corner. complish? What values should our institutions and prac-
The standoff in that room, though, was puzzling. We tices be built upon, embody, and achieve?
asked the insurers if they believed that everyone should The language of values has another virtue: Unlike
have access to insurance whatever their risks: Yes, they health policy mavens, most Americans are baffled by the
agreed, everyone should have access to insurance. So, alphabet soup of program acronyms, economic models,
they were in favor of universal access, right? No, they and the difference between cost-benefit and cost-effec-
tiveness analyses. Heck, most of us can’t explain the dif-
ference between Medicare and Medicaid. But we all un-
Thomas H. Murray, PhD, is president of The Hastings Center. derstand what values are, and we can defend our prefer-

ii The Hastings Center


ences among them. Which leads to another reason The Second, when we acknowledge, as we must, that our
Hastings Center undertook this project. goal is health, we are obliged to think much more broad-
Values can be wielded like cudgels to batter your oppo- ly than our patchwork system of health care. Healthy chil-
nents. That, unfortunately, has been all too common in dren, healthy adults, and healthy communities are the
recent political discourse. But values worth taking serious- outcome of many factors—from decent housing and safe
ly—including all the values addressed in this collection of areas for play and exercise to good jobs and schools.
essays—are far more subtle, multifaceted, and interesting Health care, crucial for episodes of acute illness and for
ideas that can cross political boundaries. Liberty, Bruce the care of chronic diseases, is a significant but not domi-
Jennings reminds us in an echo of Isaiah Berlin’s classic nant determinant of a community’s health. As responsible
formulation, includes both freedom from and freedom to— stewards of community resources, we should invest our fi-
and each of those meanings of liberty deserves attention in nite public funds according to where they will do the most
health reform. Liberty can mean the freedom from the im- good. At times the best investment for health may be in
position of a particular health plan and physicians; but it education, job creation, or environmental protections, not
also demands a health care system that does not deny a in health care.
would-be entrepreneur the freedom to pursue her vision, a Third, the practice of individual underwriting in
freedom not available to the parent of a child with dia- health insurance—making it harder to get the sicker you
betes, for whom health insurance would be unaffordable are—should be given a prompt funeral and buried with a
outside the protective umbrella of a large group policy. stake through its heart. A concept such as actuarial fair-
We chose the authors of these essays to represent a ness—which makes good moral sense in commercial in-
broad spectrum of beliefs. We assigned each of them a surance where risks are voluntary and the losses measured
particular value to address, but we did not tell them what in money—has no place in deciding who gets access to
to say about it, other than to display the complexity resid- the health care they need.
ing within each value and spell out the policy implications Fourth, efficiency and communal responsibility are es-
of taking that value seriously for American health reform. sential if we are to have an affordable, effective, and sus-

Core American values, rather than existing in ineluctable tension with one
another, form a sturdy, mutually reinforcing foundation for health reform.
Universal participation may be a concept whose time has finally come.

In reading these essays, I found moments of great illumi- tainable health care system. This will require, at a mini-
nation and insight along with occasional areas of disagree- mum, systematically studying and improving the quality
ment; familiar ideas displayed in new and revealing as- and effectiveness of what we do in the name of health
pects; new arguments, distinctions, and concepts. I was care. It will also require restructuring incentives so that
provoked, enlightened, and occasionally surprised. I hope providers are rewarded for results rather than for the num-
that other readers will have a similar experience. bers of procedures or tests they perform. There is good ev-
Most of all, I came away convinced that values are the idence that such changes would also lead to a higher qual-
beating heart of health reform, that these authors have ity of care.
begun a marvelous conversation about those values, and Finally, the concept the task force developed more than
that the implications for American health reform are con- fifteen years ago—universal participation—may be one
crete and vitally important. A handful of ideas stand out. whose time has finally come. The core idea is simple
First, simplistic understandings of values are deceptive enough: everyone should be responsible for participating
and harmful to private insight and public discourse. Lib- in whatever way is appropriate; when anyone needs health
erty, properly understood, is not the opposite of equality; care that is reasonably effective and not financially ru-
justice, not the opposite of liberty; and responsibility, both inous, the care will be there for them. I was delighted to
personal and social, is crucial to the full realization of lib- find the concept, if not the term, endorsed so often in
erty and justice. Efficiency, an instrumental value rather these essays.
than an end in itself, is intimately related to quality, soli- Whatever combination of private and public programs
darity, stewardship, and justice. Core American values, we choose, it’s a good time to connect American values
rather than existing in ineluctable tension with one an- with American health reform.
other, form a sturdy, mutually reinforcing foundation for
health reform.

Connecting American Values with Health Reform III


State of New Jersey
OFFICE OF THE GOVERNOR

I AM PLEASED to present to you The Hastings Center’s volume, Connecting American Values
with Health Reform. The issues that are analyzed in this volume are of enormous importance to
New Jersey and to the United States, and they have and will continue to be of great importance
to me as governor of New Jersey.
Health care policy is often described as an arena of intense partisan and ideological division.
But there are also important areas of consensus that reflect agreement about some basic, core val-
ues. Health care reform will be most successful if it draws on these common values.
Both progressives and conservatives want to expand access to care. Everyone recognizes that
lack of access for low-income people violates our national commitment to civil rights and that it
ultimately threatens the viability of the mixed public-private health insurance system. In 2008,
New Jersey passed a major expansion of our FamilyCare program to mandate health coverage of
children and to provide free or subsidized health insurance to low- and middle-income families,
and this bill received massive Republican and Democratic support.
Both progressives and conservatives want to contain health care costs. Progressives recognize
that relentless cost increases will crowd out other social priorities and that low-income people
bear the heaviest economic burden when health insurance costs compete against annual raises. I
am a proud progressive, but it is because of my core principles that I know we have to act when I
see New Jersey’s bill for health care now having grown to almost a third of the state budget. I and
my administration have worked hard to make progress on reducing health care cost growth, in-
cluding significant reductions in excess hospital capacity and reforms to the insurance market.
Both progressives and conservatives want to build health care IT infrastructure and recognize
that—as with interstate highways (another area of political consensus)—without government in-
tervention, health IT will not be developed. Both progressives and conservatives understand the
compelling moral and policy case for investing in prevention and not just in illness treatment.
These themes represent major common ground from which to work toward national health
reform.
The essays included in this book can help to elucidate the beliefs that we share, and where dis-
agreements over principle are more intractable. But to make progress on the areas on which we
agree, we will also need to overcome the sense that health reform is a zero-sum game in which
one ideology and one party can only win if the other loses. It is my hope that this volume can
help us to recognize that getting health care right reflects American values.

Jon S. Corzine
Governor
State of New Jersey

iv The Hastings Center


Liberty without equality is a name
of noble sound and squalid result.
—L.T. Hobhouse

Liberty
Free and Equal

BRUCE JENNINGS

A
merica is the child of John Locke, the great no exception, and we need to think carefully and critical-
philosopher of liberalism and natural rights. This ly about its history, meaning, and political implications.
commonplace observation holds a key to under- Properly understood, liberty should be compatible
standing the politics of health reform in the United with other ethical values that have often been pitted in
States. The tradition of liberalism (in the philosophical conflict with it, such as equity. Such a conflict has been
sense of the term) is still the context of our political thought to arise, for example, when allowing all individ-
morality, our constitutional law, and much of our public uals the freedom to accumulate as much as they can un-
policy. Liberty is the fundamental value of American pol- dermines the capacity of the entire society to ensure that
itics; not the only one, to be sure, but the fundamental each individual receives a fair share. Why is this clash be-
one nonetheless. Liberty has been central to the ethical tween appropriation and redistribution seen as a clash be-
justification for health reform in the past, and it will con- tween liberty and equity? In order to set up this conflict
tinue to be in the future. in the first place, one must conceive of liberty as the un-
As a fundamental value in American life, liberty has bridled expression of possessive individualism. But this is
several interesting characteristics. It is talked about a lot; not the only or the most fruitful way to understand lib-
the word itself is often used, both in political and every- erty. Herein lies my principal point: progress in establish-
day speech, but even when the word is not spoken, the ing an ethical and political justification for health reform
idea is there. Liberty is pretty much synonymous with depends on reconciling liberty and equity, at least in the
freedom and, in bioethics jargon, with “autonomy.” Lib- arena of health affairs. We must break out of the ideolog-
erty often goes incognito, its resonance embedded in ical grid that sets liberty and equity in opposition, indeed
other values or ideas that on the surface seem to be about in a zero-sum relationship such that one of these values
something else. For instance, liberty resides in terms like cancels out the other. The health reform conversation has
privacy, choice, property, civil rights, entrepreneurialism, to be reframed at the grass roots level so that a new way
markets, dignity, respect, individuality. Values so ubiqui- of seeing what liberty is and what it requires will grow
tous are often taken for granted and not sufficiently scru- out of that conversation. One tenet of this movement
tinized. They therefore have great political power yet are should be that equity in access to health care, reduction
vulnerable to cynical misuse and manipulation. Liberty is in group disparities in health status, and greater attention
to the social determinants of the health of populations
and individuals are all policy goals through which liberty
Bruce Jennings, MA, is director of of the Center for Humans and
will be enhanced, not diminished.
Nature and a senior consultant at The Hastings Center. He teach-
es ethics at the Yale School of Public Health.

Connecting American Values with Health Reform 1


Unveiling the Statue of Liberty
by Edward Moran

What Liberty Has Meant

T he history and politics of health


reform is an object lesson in this
regard. In the past, appeals to the
value of liberty have most often been
made by opponents of governmental
involvement and structural change.
In the street language of American
politics throughout the twentieth
century, the main threat to liberty
was “socialism” (a.k.a. big govern-
ment), and the key plank of the in-
dictment against health reform plans,
from Woodrow Wilson through Bill
Clinton, was the specter of “socialized
medicine.” The main ally of liberty in
the same period was free market
competition. Health reformers strug-
gled (mostly in vain, it must be said)
against this interpretation of liberty.
They countered with an appeal to the serving” poor. I believe that we will significant political effect—was the
language of rights and to the counter- never be able to resolve these di- fear of losing personal liberty, and in
vailing value of equality. (Equality’s chotomies or untangle this web. In- particular, fear of losing the freedom
aliases are equity, fairness, social jus- stead, what we need to do is to to choose one’s own doctor and to
tice, solidarity.) change the subject and reconceptual- control one’s own health care. The
Stepping back, we can see that ize the terms of these past dead-end television advertising campaign
health reform has been caught in the debates. against the Clinton plan, sponsored
same web of dichotomies and con- The most recent large-scale health by a health insurance industry trade
flicting values that have ensnared reform effort in the United States, group and featuring the concerned
every other facet of progressive and during President Clinton’s first term middle-class couple Harry and
welfare state measures during the last in the early 1990s, featured each of Louise, focused on the loss of liberty
century. Some of the worst snarls in these snarls. No doubt there are many and the erosion of quality that the
this intricate web are: (1) individual reasons why this plan was defeated in plan would bring about. These pro-
responsibility and choice versus social Congress, perhaps not the least of fessionally produced ads used the
assistance; (2) market initiative and which was that big business ultimate- concept of liberty very artfully.
competition versus governmental reg- ly decided that it could get a better What is it about liberty that turns
ulation and bureaucratic red tape; (3) deal to hold down health care costs it into an arrow in the quiver of op-
efficiency versus entitlement; (4) au- from a private managed care ap- ponents of health reform? Is there a
tonomy (rugged individualism) ver- proach than it could from Clinton’s way to reframe it and to develop an
sus elite paternalism (Big Brother, the combination of managed competi- alternative way of using it? Is there
nanny state, father knows best); and tion and a global health care budget. any reason to think that such a refor-
finally, at the personal, gut level, (5) But at the level of public opinion, the mulation would have any traction in
fear of losing current benefits and debate tended to center more around forthcoming political debate and the
quality services versus guilt based on individual liberty versus social equity. policy process? These will become in-
a sense of justice and concern for A mainstay of the attack on the Clin- creasingly important questions, I be-
those excluded from the current sys- ton plan—policy experts dismissed lieve, in the round of health reform
tem, especially children and the “de- this as obvious nonsense, but it had a debate that is now beginning.

2 The Hastings Center


What Liberty Should Mean
Establishing an ethical and political justification for
T he concept of liberty has two dif-
ferent facets, which are usually
referred to as “negative liberty” and
health reform depends on reconciling liberty and equity.
“positive liberty.” Negative liberty is
about being free from obstacles or about negative liberty. And what is uals at particular times, but such ac-
constraints: it is about having free- true of health care is true as well of cess has been shown to have little ef-
dom of choice—even the freedom to health itself, or of health status. fect on population health as a whole.
make mistakes and poor choices. The positive, relational, and en- And even at the individual level, the
Having personal security and civil abling side of liberty is what links it most important and challenging pol-
rights ensures negative liberty. Posi- to equity. The zero-sum relationship icy goal is access to health, not mere-
tive liberty is about being free to have between liberty and equity is an opti- ly access to clinical medical care.
options—being enabled or empow- cal illusion that comes from an exclu- Building a system that generates or
ered to make choices or realize per- sive focus on negative liberty. Positive promotes health requires that people
sonal goals. Having the right to free- liberty is the concept that reminds us have access to many specific and pos-
dom of speech is a negative liberty; that the well-being of one individual itive aspects of their natural and so-
having access to an education that is not a function of isolation but of cial environments. Achieving greater
gives you something thoughtful to context, community, and mutual in- health for the whole population—a
say is a positive liberty. Positive liber- terdependency. Equity is about mu- healthier nation—will require large-
ty is about having others do some- tual flourishing; negative liberty is scale social reform and institutional
thing for or with you that gives you about individual flourishing no mat- transformation. These changes point
the opportunity to change your life ter what the condition of others; pos- in the direction of a more global kind
or achieve your goals. In a nutshell: itive liberty is about the connection of equity and social justice.
negative liberty is about “don’t tread between individual flourishing and The role of liberty will change in
on me”; positive liberty is about “I mutual flourishing. Positive liberty health reform debates when two
need you to help me up.” reminds us that no single individual, things happen. First, we must see that
The libertarian interpretation of no matter how wealthy or powerful, health reform involves equitable ac-
liberty and the privatized market can really be free except in a context cess to the social preconditions of
model of health care err by focusing of social justice and the common health, as well as to health care. Sec-
too exclusively on the negative side of good. ond, we must see that when anyone
liberty. Health care is inextricably lacks such access, the liberty of all
bound up with the value of liberty, (not just of those who experience the
not simply because it prevents illness  Policy Implications  inequity) is compromised. This, I be-
from limiting your life decisions, but lieve, is where the health policy con-
also because it enables you to use
your freedom more richly, to live
your life in more meaningful and
T he health reform debate of the
coming years will have a broader
focus than past reform debates. It will
versation is going in the years ahead,
and as this shift occurs we will re-
think the meaning and uses of the
worthwhile ways. Health care is not not just be about acute-care health value of liberty in political argument.
simply about preserving you from the insurance reform and access to clini- Liberty rethought can then be one of
“outside” interference of others or of cal, treatment-oriented medical ser- the touchstones for a democratic,
disease; it is also about obtaining the vices and technologies. Instead, it will grass roots movement for health re-
active assistance of others so as to en- take up the larger structural determi- form that will demand health justice
hance the types of activities you can nants of health and health promo- in a nation of free and equal
pursue and the kinds of relationships tion. The access to acute care and persons.
you can have. Thus, health care is as high technology clinical services is
much about positive liberty as it is very important to particular individ-

Connecting American Values with Health Reform 3


Nothing is to be preferred before justice.
—Socrates

Justice and Fairness


Mandating Universal Participation

PAUL T. MENZEL

Why Mandated Universal Coverage Is Just

C
onvictions about justice are a deep and persistent
and Fair
force in health care. It seems distinctly unjust and
unfair, for example, that one victim of a disease
dies or is permanently impaired and financially devastat- We have already collectively decided to prevent hospitals
ed, while another with the same disease is readily cured from turning away the uninsured. In such a context, allow-
and lives financially unscarred. ing insurance to remain voluntary is unfair to many of the
Yet convictions about what is unjust do not necessari- insured. The obvious way to alleviate this unfairness is to
ly steer us quickly toward universal access to basic care. mandate insurance.
Beyond political and economic self-interest, conflicts be- Since 1989, by federal law (the Emergency Treatment
tween justice and allegedly competing values like liberty and Labor Act), hospitals have been prohibited from re-
may intrude. Also, there are different senses of justice it- fusing acute care to those who cannot afford to pay. Con-
self, varying widely across the moral and political spec- sequently, $100 billion of care is annually “cost-shifted”
trum. Those who think it unjust that one person can be onto patients who can pay, almost all of whom are in-
ruined by an illness that leaves somebody else, who has sured. This shift raises the average annual health insur-
greater resources, unscathed, are looking to a relatively ance premium roughly $1,000 for every insured family.
egalitarian sense of justice. That sense pushes toward uni- Some of the uninsured are working families and young
versal access and its equitable financing. Some libertarian singles; when they need emergency care and get it at little
views of justice, on the other hand, contend that those cost, others who are economically similar but have chosen
who have no contractual or special relationship with the to insure end up invisibly footing part of the cost. Ar-
unlucky victim of disease—and have not themselves ex- guably, those uninsured who so benefit without bearing
acerbated her plight—have no obligation to assist her. any share of cost are unfairly free-riding. Only two ac-
Despite these complications, several claims about jus- tions can avoid this: either repeal the rescue requirement
tice and fairness may be based broadly enough in U.S. on hospitals, or mandate insurance. Few support the for-
moral and political culture to guide society’s debate. A mer, so let’s face the matter and mandate insurance.
case for mandated universal coverage built on seven such A mandate that everyone be insured is unfair unless in-
claims is outlined below, followed by a discussion of how surance is affordable, but in any multipayer system, afford-
such a policy embraces the values of liberty and justice. ability requires both income-related subsidies and restrictions
on the behavior of insurers.
Given the cost of even basic insurance, many people of
Paul T. Menzel, PhD, is professor of philosophy at Pacific Luther-
an University and has published widely on philosophical ques-
modest means who do not qualify for Medicaid cannot
tions in health economics and health policy. reasonably afford insurance without a subsidy. In addi-

4 The Hastings Center


tion, insurance will not be affordable their own choices—by avoiding wise and prudent insurance be made?
for anyone who already has health overeating that exacerbates (or even Arguably, the person of modest
conditions likely to require higher- creates) diabetes, for example. It fol- means. The first demand of justice in
than-average annual expenditures un- lows that the cost of insurance should health care is for universal access to
less insurers are prevented from carv- seldom depend heavily on a person’s care that has been proven effective
ing out their favored clientele by health conditions. and whose expense-to-benefit ratio is
means of preexisting condition exclu- We can’t have it all: setting hard pri- not so high that it leads thoughtful,
sions and “risk-rated” premiums. orities among different health care ser- middle-class subscribers to pull it
Unless insurance is mandatory, it is vices (“rationing,” if you will) is not un- from the package they are willing to
unfair to bar insurers from using preex- just or unfair to patients who would fund. The compelling obligations of
isting condition exclusions, waiting pe- have regarded such limits as wise and those who are well to help fund care
riods, and risk-rated premiums. prudent prior to becoming ill. for the sick, and of the relatively
Feasible access to insurance for the Everyone has reason to worry wealthy to help fund insurance for
people who most need it suffers about the expenditures providers and the relatively poor, stop at this line.
greatly when voluntary insurance that patients will run up. Once insured— People can continue to argue about
permits the healthiest to go without and once ill—patients will want to whether health insurance should be
coverage gets combined with wide get and providers will want to pro- more insulated than this from varia-
latitude for insurer strategies to re- vide all the care that has any prospect tions in affordability, but in a society
cruit optimal subscribers. The effec- of net benefit, regardless of how small committed to only modest measures
tive path to access, however, is not the benefit is, or how expensive its of income redistribution generally,
merely to bar insurers from using cost. Every system of insurance thus collective action will be out of bal-
such strategies. To do so would ex- needs to police the care it provides, ance if it guarantees everyone access
pose them to potentially lethal eco- restricting care at the margins of to care above this line. Of course,
nomic risk (through “adverse selec- (low) benefit and (high) expense. Call some will wish to include greater cov-
tion”). It would also raise premiums those limits “priority setting,” “prac- erage, including unproven care of
for healthy young people, who in tice guidelines,” “rationing,” or what- highly speculative benefit. So be it:
turn would be even less likely to in- ever: they are absolutely necessary to they are free to buy up to it with their
sure; thus the number of uninsured
might actually increase! People who
want to postpone insurance, thinking Justice does not require universal access to all care,
its expense to be a poor bargain given
their current good health, should not but only to “basic” care.
be allowed to pick their time to get
insured. To receive benefits in times control costs in a system of insured own devices. Keeping the package of
of crisis, people need to pay in all care. They are not unfair to patients basic care relatively lean and thus af-
along. just because the patient might have fordable to subscribers and sustain-
Justice between the well and the ill benefited from the marginal care able for taxpayers will never be easy,
requires that they share most of the fi- withheld. If knowledgeable sub- and pressures from particular interest
nancial burdens of illness, as well as in- scribers, in selecting insurance before- groups will often need to be resisted.
surance. hand and having to pay for it with Financing insurance through the
Mandating insurance together premiums or taxes, would have de- current taxable income exclusion for
with sharply restricting insurers’ prac- cided that such care was not worth its employer-paid premiums is highly re-
tices is not only practically necessary higher premium cost, then sub- gressive and hardly just. If purchased
to achieve access. It also fundamen- scribers’ own values are the source of insurance continues to play a major role
tally aligns with justice between the the limitations that define “wise and in health care, a less regressive, fairer
ill and the well. Some principle of prudent” insurance. subsidy for access is required.
just sharing between them emerges Justice does not require universal ac- Currently, roughly half the popu-
from widely held convictions about cess to all care, but only to “basic” care. lation is insured through employer-
the importance of assuring equality Justice can tolerate additional, more ex- sponsored plans, whose premiums are
of opportunity. One attractive ver- pansive tiers of health care for those who excluded from the employee’s taxable
sion of such a principle is that the fi- choose to pay for it with their own ad- income. This roughly 40 percent tax
nancial burdens of medical misfor- ditional means. subsidy (when the employer’s and
tune ought to be shared relatively From whose perspective—the rel- employee’s FICA and Medicare taxes
equally by well and ill alike, except atively wealthy subscriber, or the per- are included) is distinctly regressive,
when people can be reasonably ex- son of more modest means—should benefiting those in the higher tax
pected to minimize those burdens by the decision about the boundaries of brackets the most. Such a structure

Connecting American Values with Health Reform 5


for the society’s primary incentive for • The prevention of unfair free-  Policy Implications 
purchasing insurance is hardly fair. A riding—a driving force behind
second questionable aspect is the sub- the move to mandatory insur- • Insurance for basic care
sidy’s lack of any limit on the premi- ance—is itself based in the value must—at least eventually—be
ums excluded; cost control in health of individual responsibility: no mandatory and universal.
care is thus discouraged, and general one should get to ride the system
affordability aggravated further. Even without contributing to its up- • If the system retains employer
if health insurance remains signifi- keep. or individual premiums, they
cantly based in individual or employ- must not be significantly higher
er subscription, a capped tax credit is • The principle of just sharing for people who are likely to be
fairer. It would also likely be more ef- between the well and the ill is chronically ill than for those who
fective in persuading lower-income key to the argument for universal are likely to be well.
employees and low-payroll employers access to basic care, but it is
to insure. grounded on convictions about • Guaranteed, universal access
equal opportunity for human should be to a limited scope of
How Mandated Universal well-being. That focus of justice care that is of proven effective-
Coverage Supports Liberty on equal opportunity, not on ness and reasonable cost-effec-
equal well-being itself, inherently tiveness. Costs must be con-

S ome claim that individual liberty


and responsibility conflict with
both universal access and any form of
includes liberty and responsibili-
ty. The enterprise of achieving
justice is therefore not a matter
trolled, even if this requires set-
ting priorities and excluding
some kinds of care. People
mandatory or societal insurance. of “leveling,” but of expanding should be at liberty, however, to
Mandating insurance may be just and and energizing. buy more inclusive insurance.
fair, but it certainly appears to limit
liberty, and whatever relatively uni- • Even limitations on covered • Both single- and multipayer
form level of “basic care” is used to services—that curse of health systems can be just. Any multi-
define universal access rides care politics, “rationing”—may payer system will have to set a
roughshod over the often very differ- at bottom be tied to the concept common framework for basic in-
ent views individuals have about of liberty, insofar as these limita- surance and sharply restrict in-
what health services merit funding. tions reflect our liberty as citi- surers’ efforts to recruit the most
The challenge in countering such a zens to determine what and how profitable subscribers. Financial
view is to consider liberty in its fuller much will be spent on health incentives should promote fair
context, as bound up with responsi- care, using our values. competition both among private
bility—where both are connected to insurers and between private and
justice and fairness: Arguments for universal access and public insurance.
mandatory insurance that invoke jus-
• Lack of access to basic care se-
tice and fairness can thus be based in • The current tax subsidy for pri-
verely undermines people’s abili-
fundamentally liberty-friendly values. vate insurance—the uncapped
ty to be responsible for them-
There is broader room for moral and exclusion of employer sponsored
selves and their families. Un-
political agreement than at first meets premiums from taxable in-
treated illness has this effect, and
the eye. come—should be changed to a
so does the financial hardship
(even bankruptcy) often caused subsidy that is less regressive and
by uninsured medical expenses. more effective at controlling
costs.

6 The Hastings Center


Man is condemned to be free; because
once thrown into the world, he is responsible
for everything he does.
—Jean-Paul Sartre

Responsibility
Shane and Joe

JIM SABIN

W
e in the United States are deeply committed to raising, a ceremony in which the community joins to-
“responsibility” as a core American value. gether to help individuals meet a basic need.
Being responsible and taking responsibility are Shane exemplifies responsibility as individual action—
good. Being irresponsible is bad. But “responsibility” making your own choices, doing what has to be done,
means very different things to different people. As a re- and doing it on your own. For cowboys like Shane, the
sult, calling for “responsibility” in U.S. public discourse is emblem of responsibility is the six-gun and the self-re-
like waving a red flag at a convention of bulls—it elicits liance and strength that comes from skill at knowing
passion, rancor, and disorderly conflict. when and how to use one.
There’s no better place to go to understand the two These contrasting images of what responsibility
main ways Americans take responsibility as a guiding means—communal barn-raising versus individualistic
value than the movies, especially westerns. Take the 1953 cowboy gunslinging—lie behind the current competing
classic, Shane, in which lit- health care reform propos-
tle Joey Starrett is torn be- als. They are also the
tween two icons of respon- V alues come from the gut, not the mind. source of some of the pas-
sibility—his father, Joe, the sion, rancor, and disorder-
homesteader, and Shane, Our visceral responses to the values that ly conflict we have seen in
the mysterious gunslinger our ineffectual previous ef-
cowboy. Joe and Shane em- reform proposals embody are a significant forts at health care reform.
body the two poles of re- Our love affair with the
sponsibility in U.S. moral part of what attaches us to the policies we myth of the heroic cowboy
discourse. enhances the attractiveness
Joe exemplifies respon- favor and sets us against competing options. of market-based reform
sibility as social solidari- proposals. But in place of
ty—building a caring community that takes responsibili- the cowboy, market proposals envision a heroically em-
ty for the welfare of its members. Joe is committed to powered “consumer.” This swaggerer is armed with con-
farm, family, and his nascent frontier town. For home- fidence, information, and choices when striding into the
steaders like Joe, the emblem of responsibility is barn- health care “marketplace” to make prudent “purchases” of
high-quality, low-cost health care. The consumer enforces
Jim Sabin, MD, is a clinical professor of both ambulatory change via purchasing power and the invisible hand of
care/prevention and psychiatry at Harvard Medical School and di-
rector of the Harvard Pilgrim Health Care Ethics Program. the market, not a six-gun. Some of the intuitive emotion-
al appeal of reform proposals that depend on competitive

Connecting American Values with Health Reform 7


Torn between two models of
responsibility. Left to right: Brandon
de Wilde as Joey, Van Heflin as Joe
Starrett, and Alan Ladd as Shane.

called “Shane! Come back!” at the


end of the film—two new icons en-
tered the U.S. health care reform dia-
logue—Harry and Louise. In one ad-
vertisement, Harry and Louise are sit-
ting at their kitchen table. In the
background an ominous voice says
“the government may force us to pick
from a few health care plans designed
by government bureaucrats.” Harry
and Louise agree—“Having choices
we don’t like is no choice at all. They
market forces comes from our cultur- ation—citizens contribute funds via choose. We lose.” In another, Harry
al ego ideal of the self-reliant cowboy, their taxes to allow patients and clini- asks Louise about the insurance prac-
who is always prepared to put “skin cians to collaborate on behalf of tice of community rating. She replies
into the game” of life. health. disapprovingly, “Everyone pays the
We can also discern the high value Like westerns, health care reform same rate, no matter their age, even if
we place on heroic cowboys like proposals envision villains as well as they smoke or whatever.” Their
Shane in the language of obituaries. good guys. In Shane, the bad guys are friend Pat reports that his health in-
The dead person is extolled for hav- ranchers and their hired thugs. For surance costs more than doubled
ing “fought a brave battle” against an market proposals, the bad guys are with community rating—treating
illness that ultimately prevailed. An the demanding, entitled individu- everyone the same was a disaster for
old joke speaks to the worldview be- als—free-riders who expect others to his community. Harry is shocked—
hind all our talk about fight: In India, satisfy their expensive tastes in health “Congress can do better than that!”
death is a potential step away from care, but who are unwilling to take Harry and Louise put nails into
reincarnation and toward Nirvana. In responsibility by putting any of their the coffin of the Clinton health re-
Europe, death is an existential own financial skin into the game. For form proposal. Their power came
tragedy we all must face. In the Unit- single-payer proposals, the bad guys from looking like ordinary Americans
ed States, death is optional. When I are insurers who siphon money away and drawing on core American val-
was growing up, boys were taught from health care and into corporate ues. They invoked an intrusive nanny
that only sissies give up a fight. That profits and executive pay packages. state that imposes limited choices on
macho approach to life may be well These are wildly oversimplified the population and takes away the
suited to trench warfare, but its use- cartoon images of our major health opportunity to chart one’s indepen-
fulness as a guide for health care re- care reform proposals. But values dent path in life. The attack on com-
form is limited. come from the gut, not the mind, munity rating raises the specter of
and the gut is not a sophisticated people who refuse to take responsibil-
Good Guys and Bad Guys thinker about the nuances of alterna- ity for their own choices (“smoking
tive policy options. In addition to the or whatever”) or for the embarrassing

P roposals that emphasize universal


coverage—like the single-payer
plan—are enhanced by our beloved
logic and facts on which competing
proposals are based—and the vested
interests that support and oppose the
fact that they’ve become old and cost-
ly. Like Shane, Harry and Louise
want individuals to be “free” to make
myth of social solidarity in an Edenic, different options—our visceral re- their own choices and to take respon-
barn-raising frontier. Building on the sponses to the values they embody are sibility for any burdens their health
vision of a caring community that a significant part of what attaches us care needs place on others.
joins forces, the single-payer plan en- to the policies we favor and sets us
visions a society that pools its re- against competing options.
sources to minister to the health care In 1993, during the Clinton
needs of the individual. The energy health care reform process—and
for change comes from social cooper- forty years after Joey mournfully

8 The Hastings Center


 Policy Implications  public plan that covers everyone. But choice) and tiered pharmacy benefits
it threads its way through the mine- (letting me get the pricier, branded

O ne reason the Massachusetts


health care reform plan has at-
tracted so much attention nationally
field of competing values well enough
to be acceptable to a substantial ma-
jority and to evade the accusation of
drug if I wish, but forcing me to pay
more). In principle, a libertarian pa-
ternalist could support the Massachu-
is the way it addresses the deeply being “socialized medicine.” At this setts mandate for individually pur-
rooted American standoff between point, the opposition is too small and chased insurance because those who
the proponents of individual respon- too divided to undermine public sup- object to the mandate can pay the tax
sibility (Shane) and societal responsi- port. penalty alternative instead, and those
bility (Joe Starrett). The architects of Much like the Massachusetts plan, who follow it can choose their insur-
the Massachusetts plan like to point the ostensibly oxymoronic political ance from a long list of options.
out that it requires everyone to take philosophy of “libertarian paternal- In his inauguration speech, Presi-
responsibility. Individuals are re- ism” (described recently by Richard dent Obama invoked responsibility
quired to purchase health insurance Thaler and Cass Sunstein in their as a major theme—“What is required
but are free to choose among a large book Nudge) seeks to bridge the gap of us now is a new era of responsibil-
number of private (“nongovern- between those who make individual ity—a recognition, on the part of
ment”) plans. Employers are required freedom the top value and those who every American, that we have duties
to contribute. The state is required to put the social good into first place. to ourselves, our nation and the
pay for those too poor to buy their Libertarian paternalists favor policies world.” It sounds as if the president
own insurance. that engineer choice in ways that in- wants to side with both Shane and
Nobody loves the Massachusetts fluence people’s behavior without Joe Starrett. That’s a direction our
plan—it is too awkward and complex closing off their options. In health forthcoming health care reform poli-
to be lovable. Libertarians hate the care, libertarian paternalists would cy debate should take.
individual mandate. Single-payer ad- support tobacco taxes (nudging me
vocates hate the failure to create a not to smoke but still giving me the

Connecting American Values with Health Reform 9


We must all hang together or assuredly
we shall all hang separately.
—Benjamin Franklin

Solidarity
Unfashionable, But Still American

WILLIAM M. SAGE

I
llness, we are often told, is a private matter. Accord- concern is provoked by novel pathogens, runaway tech-
ingly, none must interfere in the medical decisions nologies, and random, large-scale events.
that emerge from the confidential relationship be- The economic downturn, with its emerging consensus
tween physician and patient. Yet evidence of interdepen- that something must be done to universalize the U.S.
dence is ubiquitous in health care. One person’s malady health care system, presents an unexpected opportunity
can harm families, workplaces, clubs, churches, and to revisit health solidarity. Whether hard economic times
sometimes entire communities. Similarly, a suffering pa- are sufficiently calamitous to become a unifying force re-
tient must rely on many individuals, associational groups, mains to be seen. If so, we should be grateful that the
corporate entities, and government agencies for support streets are littered merely with dead businesses, not with
and assistance. It is, therefore, unsurprising that various dead bodies, and that toxic assets rather than toxic agents
social units claim an interest and a voice in maintaining are responsible.
health and treating disease. Beyond these base emotions, one can identify three
However, explicit solidarity has long been out of vogue sources of solidarity that reflect American society’s better
in America’s value system, despite persistent lack of af- nature. I shall call them mutual assistance, patriotism,
fordable medical care. Instead, the public has prized sci- and coordinated investment.
entific innovation, consumer sovereignty, and personal
autonomy, and has installed physicians as benevolent oli- Mutual Assistance
garchs to oversee these functions. The resulting system
delivers idiosyncratic care at enormous expense to most
Americans, while a sizable minority often goes without.
Calls for solidarity in American health care reach re-
M utual assistance rooted in both compassion and ex-
pectation of reciprocity accounts for the bulk of
U.S. health solidarity. Misfortune attributable to chance
ceptive ears mainly when spoken in fear—recently of or resulting inevitably from the passage of time—not
pandemic disease, bioterrorism, and natural disaster. Al- temptation or moral failing—typically triggers collective
though crisis is a perpetual and therefore meaningless ad- support to prevent avoidable deaths, ameliorate suffering,
jective in health policy debates, calamity seems to breed and save victims’ families from impoverishment.
togetherness. Foxholes tend to convert libertarians into Sharing the financial risk of poor health can be ac-
communitarians as well as atheists into believers. Special complished through processes of varying formality, rang-
ing from charitable campaigns (such as donations to hos-
William M. Sage, MD, JD, is vice provost for health affairs and
pitals) to means-tested entitlements (Medicaid) to full-
James R. Dougherty Chair for Faculty Excellence at the Universi- blown social insurance (Medicare Part A). These efforts
ty of Texas in Austin. openly redistribute wealth but greatly assist recipients

10 The Hastings Center


and, at least for voluntary charity, en- that charity care should be the touch- for health care are widely perceived as
hance the well-being of donors. stone for “community benefit.” fiscal power plays—schemes not only
Health is a natural area for mutual to raise revenue, but also to divert
aid because those contributing be- Patriotism private spending on health into other,
lieve that those receiving aid are seri- unspecified government projects.
ously ill and thus have no higher use
for resources than medical care. This
mitigates concerns that aid might dis-
P atriotism is a less common source
of interconnectedness in Ameri-
can health care. America’s commit-
Many Americans suspect that the in-
evitable result would be reduced in-
vestment in facilities and innovation,
courage self-help and promote wel- ment to tolerance and liberal plural- quality reductions, supply con-
fare dependency. Mutual assistance is ism is very effective at creating associ- straints, and rationing. These con-
strongest when donors can identify ational groups with shared values, cerns are reinforced by the American
with potential beneficiaries; nations which in health care spawns agendas medical profession—a grass roots
with the most generous social insur- as diverse as those of the American army of talented small businesspeople
ance programs tend to be those that Cancer Society, the Hemlock Society, who, with fierce conviction if little
are demographically homogeneous. Physicians for Human Rights, and historical justification, continue to
Mutual assistance occurs in private the Association of American Physi- construe their social prominence and
health insurance as well as public pro- cians and Surgeons. But it is not very financial success as the result of
grams. Group rates for employment- effective at motivating large national rugged individualism rather than
based coverage redistribute resources projects during peacetime.
from healthier to sicker members of
workplace risk pools. Americans
readily accept this mode of mutual The severity of the economic downturn—and the
support because they identify with
fellow workers. It is undoubtedly aggressive response it has provoked—creates an opportunity
made more palatable by the selective
subsidy awarded employee benefit to overcome entrenched political positions and recalibrate
plans under the federal tax code, by
lack of transparency regarding the public values in support of solidarity.
magnitude of the transfer, and by the
widely credited fiction that the Building loyalty to centralized sheltered competition and lavish
money involved is the employer’s governments, fostering political sta- public subsidy.
rather than the employees’. bility, and avoiding class warfare— Nevertheless, patriotism partially
Similarly, Americans routinely the conventional explanations for the motivates several core features in the
empower health care providers to welfare states of Western Europe— U. S. health care system. Those who
make decisions about how to distrib- seem unnecessary given our long- render military service to the nation
ute shared resources because they can standing federal union, our melting- are repaid in part with health care:
imagine lives being saved. A seldom- pot heritage, and our belief that con- the Veterans Health Administration
noted aspect of the backlash against tinued upward mobility serves as a is the largest component of the De-
managed care derived from percep- social safety valve. Even in post–cold partment of Veterans Affairs and pro-
tions that HMOs were converting war America, compulsory redistribu- vides lifetime benefits to millions of
otherwise acceptable cross-subsidies tion to achieve explicit ideological individuals. The enactment of
into corporate profits and thereby de- goals of equality in health care access Medicare can be viewed similarly, as
priving the health care system of sounds disturbingly Soviet (“from health security to compensate genera-
needed funds. Historically, physicians each according to his ability, to each tions of Americans who worked
charged higher fees to wealthy pa- according to his need”). Accusations through two world wars and the
tients and offered free service to poor of “socialized medicine,” most recent- Great Depression and who became
ones, a practice that eventually yield- ly hurled by former New York City old and infirm during the sustained
ed to the bureaucratic constraints of Mayor Rudy Giuliani during his brief period of peace and prosperity that
government programs and lack of 2008 presidential campaign, retain followed. As evidenced by the tempo-
equal charity from suppliers of neces- rhetorical impact because we contin- ral connection between Medicaid and
sary diagnostic and therapeutic com- ue to fear state intrusion into inti- the civil rights movement, patriotism
plements. Nonprofit hospitals con- mate personal and family decisions. to redress prior regional and national
tinue to redistribute in this fashion, America’s preference for low taxa- discrimination can also generate
reflecting the social mission assigned tion further discourages a collectivist health solidarity.
them by their constituents and the political orientation. Proposals for
insistence of the taxing authorities government to assume responsibility

Connecting American Values with Health Reform 11


Coordinated Investment ported research). Surprisingly, far political positions and recalibrate
fewer resources have been directed at public values in support of solidarity.

A third source of health solidarity


is a loosely organized but poten-
tially powerful array of coordinated
improving the productivity of health
care providers on the assumption that
professional self-governance and mar-
In my view, however, three barriers
must be removed in order to create a
more accessible, affordable, and pro-
investments that Americans can ket discipline are sufficient to gener- ductive health care system.
make to safeguard and advance their ate and disseminate best practices. First, federal fiscal politics cannot
futures. The objective of these activi- Recently, however, policy-makers continue to impede collective invest-
ties is to increase overall welfare, not have come to understand that ment in restructuring health care—
to define citizenship or to redistribute decades of regulation and subsidy an investment that will almost cer-
resources from better- to worse-off. have artificially fragmented health tainly have a large long-term payoff.
Traditional public health functions care delivery and rewarded unpro- In addition to funding the marginal
fall into this category. Epidemics and ductive behavior, rekindling interest costs of expanding coverage, the tril-
disasters generate widespread willing- in public support for health infor- lion dollars or so that have been com-
ness both to contribute funds and to matics and comparative effectiveness mitted as economic stimulus can pro-
submit to physical restrictions in research. vide the activation energy (in both
order to prevent additional physical A final, widely accepted justifica- knowledge and infrastructure) neces-
harm and to keep critical infrastruc- tion for coordinated investment in sary to transition the health care de-
ture functioning. health care is the elimination of livery system to a new, more efficient
Equally important is reducing waste. Reducing “waste, fraud, and equilibrium.
spillover economic harm through abuse” in Medicare has maintained Second, “medical individualism”
prevention and control of noncom- universal political appeal for decades cannot be allowed to paralyze the de-
municable chronic diseases—many while, unfortunately, providing little bate. Americans have built a mental
of which derive from smoking, poor actual relief from persistent growth in wall between supporting aggregate
nutrition, and lack of physical activi- expenditures. Today’s proponents of change and resisting personal change
ty. Unconstrained government tax-financed universal health cover- that entrenched interests exploit by
spending on chronic disease crowds age argue, somewhat more persua- portraying every serious reform pro-
out other productive uses of public sively, that leaving a large percentage posal as a threat to one’s own care or
funds. The burden of chronic disease of the U.S. population uninsured re- the care of one’s family. Effective re-
also diminishes both near-term work- duces access to cost-effective primary form must connect individual ser-
place productivity and long-term care, wastes expensive emergency ser- vices to population health at as many
prospects for overall economic vices, and misses opportunities to junctures as possible.
growth. This collective project is a prevent, detect, and offer timely Third, health is a major compo-
more controversial exercise of govern- treatment for disease. In Texas, for ex- nent of America’s long-term credit-
ment authority because, at first ample, the most marketable argu- worthiness and prosperity in both
glance, interventions appear aimed at ment for health reform among the our public and private sectors. Indus-
protecting individuals from the con- general public is that roughly $1,500 try stakeholders must accept that
sequences of their own conduct of the annual premium paid by each those who receive government sup-
rather than someone else’s. However, insured family is spent on care for the port in these difficult times cannot
research on social networking reveals uninsured. The risk of this approach, merely continue business as usual,
that many chronic health conditions of course, is that voter sentiment and the general public must agree
are “communicable” through shared could turn from “please spend my that the stakes justify shared sacrifice
norms, and that improved design of money more wisely” to “please give and require sustained commitment to
workplaces, schools, and communi- me my money back.” a common purpose.
ties can alter common environments
and reduce risk factors.
The production of medical  Policy Implications 
knowledge as a public good is anoth-
er established form of coordinated in-
vestment, as is support for hospital
construction, education of health
M any strands of social solidarity
exist in American health poli-
cy, even if an explicit commitment to
professionals, and patenting of bio- universal health coverage continues
medical technology (at least follow- to elude us. The severity of the eco-
ing the enactment in 1980 of the nomic downturn—and the aggressive
Bayh-Dole Act, which encouraged response it has provoked—create an
commercialization of publicly sup- opportunity to overcome entrenched

12 The Hastings Center


Knowledge is limited, whereas
imagination embraces the entire world, stimulating
progress, giving birth to evolution.
—Albert Einstein

Medical Progress
Unintended Consequences

DANIEL CALLAHAN

W
riting in 1780 to his friend Joseph Priestly, the The fruits of medical progress—and its first cousin,
British scientist, Benjamin Franklin said that technological innovation—are not hard to discern. From
with an increase in the “power of man over the near-conquest of infectious diseases by means of vac-
matter, . . . All diseases may be prevented or cured, not cines, antibiotics, and antivirals, to a reduction of deaths
excepting that of old age.” The great American Revolu- from heart disease and many other lethal diseases and a
tionary War physician, Benjamin Rush, was no less utopi- resulting increase in life expectancy for almost everyone,
an in prophesying that there will someday be a “knowl- it is a faith that has been well rewarded. We are as a na-
edge of antidotes to those diseases that are thought to be tion healthier and more prosperous because of it.
incurable.” Yet it has been, as a value, remarkably little explored,
A powerful faith in sci- as if its patent benefits put
ence as a basic human it beyond all inquiry. Any
value, matched by an T he pursuit of progress in health care has ethical interest has focused
equally strong belief in almost exclusively on
medical progress, has been led to an unsustainable rise in costs without byproducts of the drive for
a central feature of Ameri- progress, such as human
can culture from the start. a corresponding increase in benefits. subject protection in clini-
Although medical research cal trials and, lately, the use
was slow in gaining momentum, by the second half of the of embryos for research purposes. Given the massive role
nineteenth century it was well under way, and it moved of research as part of our economic, medical, and politi-
forward thereafter at a rapid pace. The establishment of cal life, there is a good deal more that can be said about
the National Institutes of Health just before World War the value of progress as a whole, and a number of issues
II, and its steady growth since then, has been a testimony worth some intense inquiry. Five that have policy impli-
to an unprecedented congressional bipartisanship and cations have caught my eye.
public enthusiasm. Some 80 percent of Americans say There is, first, the role of research and technological
they support medical research as a high-priority national innovation as a main driver of health care costs. Any
goal, and the NIH’s $28 billion annual budget shows it. number of economic studies and the Congressional Bud-
get Office have identified either new technologies or the
intensified use of older ones as responsible for about 50
Daniel Callahan, PhD, is senior research scholar and president percent of annual cost increases, now averaging an unsus-
emeritus of The Hastings Center, which he cofounded in 1969. tainable 7 percent a year. Our technological benefit is

Connecting American Values with Health Reform 13


turning into our economic bane. which are heart disease and cancer. I mention, finally, two other
Though only a minority of medical Patients must now learn, with med- places where progress is needed. One
technologies have been assessed for ical help, how to live with and proba- of them is to change the ratio of pri-
efficacy and a good cost-benefit ratio, bly die with their condition. By “care- mary care physicians to subspecialists.
they are the front line of American oriented medicine,” I mean not just Our ratio is now sliding below 20
health care: doctors are trained and good palliative care, but well-coordi- percent for the former and rising to
well paid to use them, industry nated medical assistance to manage close to 80 percent for the latter. A
makes billions of dollars selling them disease, further coordinated with so- failure to change that ratio (it is
(and resists any cost controls), and cial and family help. 50/50 in Europe) will make it almost
the public loves and expects them. Fourth, much has been made for impossible to pursue the new goals I
There is, moreover, a profound am- years of the power of disease preven- have identified. The other is to bring
bivalence among many economists tion as the best way to save money, to the drug and device industries under
about technology. They recognize it save lives, and to improve our health. greater economic and medical con-
as the leading economic problem for Those are at best half-truths. In the trol. Their idea of progress is an ex-
American health care, but they are end, sickness and death can be fore- pensive pill or device that will meet
fearful of any moves that might harm stalled but not conquered, the costs medical needs, and—via the route of
technological innovation. deferred but not eliminated. The medicalizing every seen and unseen
There is, second, the comparative only likely way to assure a good out- ache, pain, and travail—turn all de-
role of medical care and background come for prevention programs is to sires for surcease into insistent needs.
social conditions in improving make clear to the public that high-
health. Any number of technical esti- cost technologies will be severely lim-
mates over the years trace some 60 ited when the final illness arrives. The  Policy Implications 
percent of improvements in health carrot is that prevention will give us a
status to socioeconomic factors, par-
ticularly education and income.
Medical care, then, accounts for no
longer life with a higher quality. The
stick will be the message that you
should take care of yourself and not
T he pursuit of progress in health
care has led to an unsustainable
rise in health care costs without a cor-
more than 40 percent in general— expect medicine to save you when responding or equitable increase in
though the health status of the elder- your time runs out—that is no longer health benefits. Reexamining its ef-
ly is an exception, and medical tech- an option. fects should lead to a realignment in
nology in particular accounts for Fifth, Americans already live, on the way progress is valued and to ac-
their improved health in recent average, a long life of seventy-seven companying shifts in policy. We
decades. One could make a good case years. There is no need to go out of should adopt policies that promote
that improvements in education and our way to chase life extension, or the care-oriented rather than cure-orient-
job creation could be a better use of denial of death, as the sine qua non of ed medicine; changing the ratio of
limited funds than better medical medical progress. We need progress primary care physicians to subspecial-
care. Social and economic progress in removing the health disparities ists is one important step we could
may be the kind we most need, and that keep millions from reaching sev- take in this direction. Further, we
that kind of progress would have enty-seven, in reducing the social and should address social and economic
double and even triple benefits be- economic burden of disease, and in issues, both as an alternative way of
yond improved health; a good educa- coping with newly emergent condi- promoting health throughout the
tion, for example, improves both in- tions (like obesity and asthma in chil- lifespan and to achieve broader per-
dividual health and the economic dren) and medical threats (such as sonal and societal well-being.
well-being of society. antibiotic resistance). The NIH has Serious progress would mean
Third, if throwing technology at always given priority to the most turning back the clock: learning to
illness in the name of progress is an lethal diseases, with heart disease at take care of ourselves, to tolerate
increasingly expensive and economi- the top of the list. Increasingly, I some degree of discomfort, to accept
cally destructive way to go, what would argue, our priority should be the reality of aging and death (not to
might a more sensible idea of the (now) slow way those diseases kill mention the near-death experience of
progress be? My vote would be to aim us, as well as the diseases and condi- erectile dysfunction), and to see our
for a better balance between cure-ori- tions that don’t kill us (or not quick- personal doctor as someone as likely
ented and care-oriented medicine. ly) but make life a misery. Poor men- to talk with us as to have us scanned.
The emergence of chronic disease as tal health, severe arthritis, frailty in That cluster of backward-looking
the most difficult and expensive kind the old, deafness and vision impair- ideas is what I think of as common-
to manage is demonstrating the fail- ment, and Parkinson’s and sense, affordable progress.
ure of cure-oriented medicine to do Alzheimer’s disease fall into that latter
away with the nation’s major killers, category.

14 The Hastings Center


There is a sacred realm of privacy for every man and woman
where he makes his choices and decisions—a realm of his
own essential rights and liberties into which the law,
generally speaking, must not intrude.
—Geoffrey Fisher, Archbishop of Canterbury

Privacy
Rethinking Health Information Technology
and Informed Consent
LAWRENCE O. GOSTIN

A
bove all values, Americans prize freedom—the participate in research. However, if taken too far, it can
right of individuals to control all aspects of their thwart valuable societal activities such as quality assur-
lives, including the personal and the economic. ance, cost-effectiveness studies, and epidemiological re-
In many ways, both major political parties embrace indi- search if essential data are withheld from clinicians, risk
vidual freedom, with Democrats stressing personal free- managers, and researchers.
dom and Republicans economic liberty. What is often The prevailing model of privacy, both as formulated in
absent in political discourse around freedom, however, is theory and as enshrined in national policy, is doubly
the common good and an appreciation of when rigid ad- harmful. This model purports to safeguard privacy but
herence to individualism is inimical to collective welfare. actually fails to fully protect personal health information.
A core American value—privacy—is closely linked to At the same time, it significantly undermines socially
freedom and clearly illustrates the tensions between the valuable activities. President Obama’s stimulus package,
individual good and the collective good. Privacy is a the American Recovery and Reinvestment Act (ARRA),
foundational individual good that respects personal dig- authorizes $20 billion for health information technology,
nity and protects patients from embarrassment, stigma, which is a cornerstone of the president’s health care re-
and discrimination. Privacy is also a collective good that form proposals. Unfortunately, ARRA and accompany-
has societal value because it encourages individuals to ing health care reform proposals do little to change the
participate in socially desirable activities such as biomed- current privacy paradigm and, if anything, reinforce its
ical research, health care quality assurance, and public flaws.
health surveillance and response. Taken too far, however,
privacy can seriously harm activities necessary for the Privacy and Consent
public good. Privacy relating to medical records, for ex-
ample, encourages individuals to access treatment and
W ith regard to health information, the most well-ac-
cepted definition of privacy is the right of individ-
uals to control the collection, use, and disclosure of their
Lawrence O. Gostin, JD, is the O’Neill Professor of Global personal medical information. Thus, individuals retain
Health Law, Georgetown University; professor of public health,
Johns Hopkins University; fellow, Centre for Socio-Legal Studies, the right to strictly limit others’ access to their personal
Oxford University; and a Hastings Center Fellow. data. Many scholars and policy-makers even assert that

Connecting American Values with Health Reform 15


patients “own” everything to do with protected. Instead of relying chiefly The gaps in federal regulation
their body, including human tissue, on strict individual control of data by leave many patients without protec-
DNA, future cell lines, and personal means of informed consent, it would tion against privacy invasions. Con-
medical records. erect meaningful privacy and security sider the “HIPAA Privacy Rule,”
The way modern laws and regula- safeguards. which regulates “protected health in-
tions assure these entitlements is to formation” held by “covered entities”
grant patients a right to fully in- The Failure of Consent such as health plans and health care
formed consent. The Health Insur- providers. Personal data held by
ance Portability and Accountability
Act, for example, adopts this model
by giving patients the right to autho-
A lthough consent is a dominant
theme in law and ethics, in prac-
tice it fails to adequately protect per-
many entities that are not covered,
such as pharmaceutical companies,
remain unregulated. At the same
rize most uses of their personally sonal privacy and is detrimental to time, the “Common Rule,” which
identifiable data. valuable social activities. Multiple regulates human subjects research,
Granting this right certainly studies have demonstrated that pa- applies principally to investigations
makes sense when the data are to be tients do not read or understand supported by the federal government.
used for purposes detrimental to the complex privacy notices and consent Research carried out with private
individual and society, such as dis- forms, which are mostly designed to funding is often unregulated. This is
crimination in health care, employ- shield institutions from liability. Pa- in sharp contrast to most other coun-
ment, or insurance. However, it tients are also often asked to give con- tries, in which privacy regulations are
makes much less sense when each in- sent when they are sick and incapable not limited to particular health care
dividual has the power to withhold of making complicated decisions. transactions or funding sources, but
information needed to achieve com- instead apply to all health data.
Federal regulation and oversight of
privacy is also inconsistent because of
The prevailing model of privacy fails to fully the marked and confusing differences
between the Privacy and Common
protect personal health information and significantly Rules. The standards for future con-
sent, anonymized data, and recruit-
undermines socially valuable activities. ing patients vary under the two rules,
leading to contrary results. There is
no ethically principled reason for this
pelling public goods such as quality This means that consent is a poor- patchwork of regulation.
assurance, cost-effectiveness studies, ly designed tool to prevent the most
medical records research, and public common causes of privacy invasion. Undermining Socially
health investigations—even when Most professionals who access med- Beneficial Activities
potential harms to the individual are ical records—such as health care
negligible.
I propose an entirely different
conception of privacy. Privacy should
workers, health plan administrators,
and lab technicians—are already au-
thorized to do so. At the same time,
A primary focus on consent is also
harmful to the social good. In-
vestigators report a diminished ability
be understood as an individual’s in- many of the most visible and worry- to recruit participants, obstacles in
terest in avoiding embarrassing or ing privacy invasions occur due to se- accessing stored tissue and genetic
harmful disclosures of personal infor- curity breaches, such as when data are datasets, and increased complexity in
mation, while not significantly limit- left on laptops or databases with in- IRB procedures, causing some hospi-
ing equally valuable activities for the adequate security. tals and physicians to opt out of re-
public’s health, safety, and welfare. Relying heavily on consent rather search. A universal requirement for
This conception allows that individu- than on strong privacy and security consent, moreover, creates selection
als have an interest in limiting access assurances shifts the focus from bias, which significantly limits the
to personal data sought by insurers, meaningful safeguards to conceptual generalizability of results and leads to
employers, commercial marketers, and often toothless ones. It provides invalid conclusions.
and family or friends. But they would patients with few real choices and Rigid understandings of privacy
have a much-reduced interest in lim- burdens the health system with a new also hamper quality assurance and
iting the access of those engaged in level of bureaucracy and expense. public health activities. There is a
highly beneficial, well-defined activi- Furthermore, the prevailing model lack of clarity about whether privacy
ties for the public’s welfare. fails to safeguard personal health in- and research regulations apply to
This would require a fundamental formation both because it leaves gaps these vital activities. As a result, clin-
shift in the way in which privacy is and because it is inconsistent. ics, hospitals, and public health agen-

16 The Hastings Center


cies feel highly constrained when they nation’s most pressing health prob- sures to protect data privacy and se-
seek access to or use personally iden- lems. These are critical if health care curity, harms that could result from
tifiable health records. reform is to succeed. data disclosure, and the potential
The prevailing conceptualization public benefits. An alternative frame-
of privacy as synonymous with strict  Policy Implications  work could also include a certifica-
individual control also defies com- tion for entities that undertake large-
mon sense. We all have our own pet
likes and dislikes, which is fine if each
decision only affects the individual
W hat is urgently needed is a
bold approach that would
make federal regulations more effec-
scale data collection for defined
health purposes or to link data from
multiple sources for the purpose of
making it. However, allowing each tive in safeguarding privacy, more providing more complete,
person to make her own decisions in uniform and fairer in application, anonymized datasets. Federal moni-
ways that disrupt the common good and less likely to impede socially ben- toring and enforcement would ensure
causes a deep social problem. Think eficial activities. A new framework to regulatory compliance, and legal
of the consequences of granting indi- the oversight of health records would sanctions would prohibit unautho-
viduals a virtual veto over each and emphasize data security, privacy, rized attempts to make donors of
every proposed use of their personal transparency, and accountability. anonymized data identifiable again.
information for the foreseeable fu- Mandated security would include Information technology certainly
ture. A patient might say, for exam- state-of-the-art systems with secure will be a key component of national
ple, that her information can be used sign-on, encryption, and audit trails. health care reform, but it will fail un-
for research on heart disease but not Privacy safeguards would require that less policy-makers safeguard privacy
for research on AIDS or STDs. This data be used only for well-defined and facilitate responsible research,
effectively thwarts a great deal of and legitimate public purposes, with quality assurance, and public health.
health services research, and the same strict penalties for harmful disclo- President Obama wants to achieve
could be said for databases used for sures. Security and privacy proce- both cost-effective health care and
quality improvement or public dures would have to be transparent strict privacy. But the stimulus pack-
health. and actors held fully accountable. By age and his health care reform pro-
The perverse effects of privacy focusing on fair informational prac- posals do little to resolve the funda-
rules make life more difficult for in- tices, patients would gain strong pri- mental flaws of an antiquated model
vestigators, physicians, and agency vacy protection, with the assurance for safeguarding privacy. The success
officials charged with carrying out re- that their personal information of health reform depends upon our
search and public health activities. would not be disclosed to their detri- ability to develop as rapidly and com-
They undermine equally compelling ment and that data would be protect- pletely as possible our understanding
individual and societal goods: scien- ed against security breaches. of what works in health care, and an
tific discovery, medical innovation, To achieve public confidence, the awareness that a false sense of privacy
cost-effective health care, and meth- new system would require careful works against that urgent need.
ods of prevention that confront the ethical oversight focusing on mea-

Connecting American Values with Health Reform 17


Try to become not a man of success, but
try rather to become a man of value.
—Albert Einstein

Physician Integrity
Why It Is Inviolable

EDMUND D. PELLEGRINO

T
o deem itself civilized, a society must protect the (witness the burgeoning of malpractice lawsuits and in-
personal integrity of its citizens. Without such surance) and public policy as well. However, one may
protection, the integrity of the society itself un- rightly ask: Is the good of the patient better served when
ravels as more and more effort goes into protecting indi- he takes charge and directs his own care, or does the ero-
viduals against the chicanery of their fellow citizens. Per- sion of trust in the physician’s integrity put the patient in
haps this is why Plato called integrity “the goodness of the danger of being morally abandoned by the physician?
ordinary citizen.” I contend that autonomy gives patients the moral
If integrity is the characteristic value for the ordinary right to reject care and protects their human dignity, but
citizen, then it’s even more important for those whose so- that patient autonomy need not interfere with the in-
cial roles are defined primarily in terms of personal tegrity of the physician—unless that right is expanded in
trust—doctors, lawyers, ministers, and teachers. Ordi- such a way that patients can demand and even direct the
nary citizens cannot be healed—or provided with advo- details of clinical care. But if autonomy is understood as a
cacy, spiritual counsel, or learning—without trust in right to demand care, it not only violates the integrity of
these helping professions. (Unfortunately, history re- the physician, it also endangers the care of the patient.
counts how some physicians in every age have failed in For the benefit of both patient and doctor, patient auton-
the trustworthiness integral to medicine.) When such omy must be understood in such a way that it can coex-
professions lack integrity, those who need their services ist with physician integrity.
will seek to protect themselves by assuring greater indi-
vidual or public control over their relationships with The Nature of Integrity
these professions.
For a variety of reasons, this is what is happening in
medicine in today’s complex societies—especially now
that medicine’s power to alter human life is unprecedent-
C lassically, personal integrity has been understood as a
person’s commitment to live a moral life. The
woman or man of integrity is honest, reliable, and with-
ed. The result is that the center of gravity for individual out hypocrisy. He will admit mistakes, be remorseful, and
decisions has shifted sharply away from the physician to accept the guilt that follows wrongdoing. The person of
the patient. That power shift has been reinforced in law integrity fulfills the obligations of his private and his pro-
fessional life, which are consistent with each other. He or
she follows his conscience reliably and predictably. This
Edmund D. Pellegrino, MD, MACP, is professor emeritus of pursuit is intrinsic to the person’s identity. To violate it is
medicine and medical ethics at the Center for Clinical Bioethics
at Georgetown University Medical Center. He also serves as to violate that person’s humanity.
chairman of the President’s Council on Bioethics.

18 The Hastings Center


In the patient-physician relation- The Empowerment of Without sanctioning obvious harm,
ship, both parties are entitled to pro- Autonomy they should yield to patients who
tection of their personal integrity. choose a less effective treatment, or a
However, the values, beliefs, and
norms that comprise integrity may
well be very different—and present
V ulnerable patients have always
worried about whether their
physicians possessed the competence
treatment of no proven use, or even
one that violates the physician’s be-
liefs about what is right and good.
different challenges—for doctor and they claimed and could be trusted to Furthermore, some physicians believe
patient. The physician needs to con- use it wisely and well. Until recently, that in the name of patient autonomy
tend with an increasingly pluralistic however, they had little power to they must protect all confidences
society that can create pressure to challenge the authority and some- even when others may be harmed—
compel him or her to accommodate times authoritarianism of their physi- for example, not reporting the inca-
patients’ differing religious, cultural, cians. Today, we live in a time of self- pacitated driver who is a public dan-
or personal beliefs. Also, the special assertion. Autonomy, the most quot- ger, or not revealing HIV infection to
nature of the patient-physician rela- ed principle of bioethics, empowers sexual partners. Others may take it as
tionship (which derives from the fact patients to challenge physicians’ an act of beneficence to exaggerate
that being sick and being healed are knowledge and judgment. Patients the severity of disease or disability to
predicaments of special vulnerabili- now have the moral and legal rights increase the patient’s insurance cover-
ty), the growth of personal freedom to be informed and to give or with- age.
of choice, the systematization of pa- hold consent. Increasingly, patients More subtle—but perhaps more
tient care, and the trend toward legal and surrogates understand autonomy important—is the physician’s grow-
resolution of moral conflicts promise as empowering them to demand the ing reluctance to urge the course that
to increase the demand for personal care they want. Autonomy has ex- he or she believes is preferable for this
and/or public control of the physi- panded to the point that it conflicts patient. Despite protestations that
cian’s clinical decisions. All these fac- with the physician’s moral or profes- they know what is best for them-
tors encourage erosion of the physi- sional judgments. selves, patients do make wrong choic-
cian’s personal integrity. The effect on the physician-pa- es. For the physician to suggest other-
On the patient side, the sick or in- tient relationship has been profound wise is to fail to respect the trust he
jured person—in a state of distress,
pain, and suffering—is compelled to
seek out and depend on the physician Is the good of the patient better served when he takes
who professes to know how to help.
The sick person and his family are charge and directs his own care, or does the erosion of trust
asked to make choices among thera-
pies, choose when life support may in the physician’s integrity put the patient in danger?
be discontinued, and decide how vig-
orously the terminally ill patient shall
be treated. Throughout all this, the and complex. On the one hand, it has promised. Refusing to “bias” the
patient and family must trust the has made that relationship more patient’s choice by revealing one’s
physician—or more likely a team of open, more adult, more transparent, own choices—and perhaps persuad-
physicians, nurses, social workers, and more attentive to the patient’s ing the patient to change his mind is
chaplains, etc.—each offering a values and wishes. Some of the edge not a true violation of autonomy.
slightly different rendition of the has been taken off physician arro- Rather, not to do so violates the prin-
choices. Often, the physician and gance and self-assurance, and the pa- ciples of beneficence and trust.
other caregivers are of different tient’s dignity as a person is better re- Beneficence does not equal “paternal-
minds, and none may know what the spected. These benefits have, howev- ism,” which relies on deception,
best choice is. This uncertainty leads er, been accompanied by trends that treating the patient as a child, or co-
to lack of trust and may prompt the are dangerous to the patient and un- ercing a choice and is itself malefi-
patient and family to go in despera- just to the integrity of physicians. For cent. To cooperate in a wrong choice
tion from Internet site to Internet one thing, many physicians feel they is complicity with what is wrong, and
site, and to nontraditional healers or are required to satisfy patient or fam- leaving the patient to decide difficult
marginal practitioners, in search of ily demands or be guilty of “paternal- issues about which the physician
answers and of someone they think ism”—the original moral sin of mod- himself may be uncertain is complic-
they can trust. Because, in the end, ern bioethics. ity in harm. Rather, what the patient
someone must be trusted. To avoid paternalism, some physi- needs is a physician who protects the
cians and ethicists argue that physi- moral right of patients to reject any
cians should be morally neutral. or all treatment after the options have

Connecting American Values with Health Reform 19


been frankly disclosed, and who will lating law and policy to make provid-  Policy Implications 
not use deception or ill-placed em- ing them mandatory by threatening
phases to change the patient’s mind.

Overriding Physician Integrity


loss of license or specialty certifica-
tion is an assault on the very person
of the objecting physician.
A s we approach another round of
health care reform, the medical
profession and the public must to-
The trajectory of efforts to compel gether find the balance that preserves

T he desire for autonomy and un-


hindered freedom of choice has
led to law and policy that override the
health professionals to provide care
they find objectionable is toward re-
laxation or abolition of conscientious
both patient autonomy and physician
integrity, for the benefit of both pa-
tients and physicians. Given how es-
physician’s objections to certain pro- objection privileges. At this writing, sential trust is in medical and health
cedures, including abortion, assisted there are organized attempts in the care encounters, we cannot trust
suicide, euthanasia, some methods of courts to block a new federal regula- physicians who shun responsibility,
assisted reproduction, and embryonic tion that protects health workers who and we do not want patients aban-
stem cell research and therapy. This refuse to provide objectionable care. doned in the midst of critical health
is not the place to argue the ethical is- The ultimate goal seems to be to and medical care decisions. For a
sues of these practices. However, re- eliminate legal protections of consci- morally viable relationship in a dem-
fusing to participate in them is essen- entious objection entirely. ocratic society, both autonomy and
tial to the moral and professional in- integrity must be sacrosanct.
tegrity of many physicians. Manipu-

20 The Hastings Center


Whether for life or death, do your own work well.
—John Ruskin

Quality
Where It Came From and Why It Matters

FRANK DAVIDOFF

A
movement has emerged within health care over ence, improvements in quality can bring benefits that
the past several decades that sees quality as the serve as a powerful counterweight to the potentially cor-
combined and unceasing efforts of everyone in- rosive effects of commerce on professional and social rela-
volved in health care—professionals, patients and their tionships.
families, researchers, payers, planners, and educators—to
make the changes that will lead to better outcomes, bet- Guardians and Gifts, Science and Commerce
ter system performance, and better professional develop-
ment; in other words, better health, better care, and bet-
ter learning. This sweeping view recognizes that the pur-
suit of quality and safety is a dynamic process, not a stat-
M edicine has historically shunned commerce. Until
quite recently, for example, it was not acceptable
for doctors and hospitals to advertise. The admonition to
ic and narrowly focused endpoint. People associated with “shun trading” is a key element in what the scholar and
the quality movement accept this pursuit as both a moral social critic Jane Jacobs has called the “guardian moral
responsibility and a serious applied science. They also be- syndrome”—a code of tightly linked moral values that
lieve unequivocally that everyone in health care has two governs one of the two systems of human survival, “tak-
jobs when they go to work every day: to provide care, and ing” (the other being “trading”). In public life, the
to make it better—a view that is entirely congruent with guardian moral syndrome, which includes the exertion of
the idea that “unceasing movement toward new levels of prowess, adherence to tradition, and the dispersing of
performance” lies at the very heart of professionalism. largess, is expressed most clearly in government, but also
Several centuries ago, the widespread adoption of in the military and religion—all of which support them-
commercial values arguably paved the way for the flower- selves through the taking of taxes, tithes, and territory.
ing of science. This essay explores the seemingly unlikely Since healers were initially members of a priesthood, it
proposition that commercial values have also served as should not be surprising that from its beginnings, health
the principal catalyst for the quality movement in medi- care was essentially a creature of the guardian moral syn-
cine when they have come up against the decidedly non- drome. Of course, like everyone else, healers need to put
commercial values that medicine has held sacrosanct. Im- bread on the table. But since they neither taxed nor
proving the quality of health care is likely to be crucial in tithed, they were forced to engage in trading. Until about
the success of health care reform, in part because, like sci- fifty years ago, however, they did so on a limited scale; to
a substantial degree, they relied instead on nonfinancial
Frank Davidoff, MD, MACP, is editor emeritus of Annals of In-
rewards from the “gift relationships” inherent in medical
ternal Medicine, and executive editor of the Institute for Health- practice. That is, they relied on deferred and uncertain
care Improvement. (but ultimately increased) rewards offered in response to

Connecting American Values with Health Reform 21


their gifts of care and healing. Rather concept of money rests entirely on sion: patients are now considered
than devoting themselves to the im- trust. “customers,” doctors and hospitals
mediate, calculated exchange that de- advertise product lines, and medical
fines commerce (such as contracts, Medicine Becomes a insurance companies consider money
investment, capital, and interest), Commodity spent on clinical care to be the “loss
healers felt themselves to be rewarded ratio.” The preoccupation with quali-
through their high social status, enor-
mous respect, and great professional
autonomy.
T he scientific awakening slowly
made its way into medicine dur-
ing the nineteenth century, leading to
ty and safety in health care has
emerged exactly in parallel with this
surge in medical commercialism. The
The underlying moral values of many new, more rational, and im- commercial values of comfort, indus-
health care in the West changed at a proved ways to care for patients, in- triousness, thrift, and efficiency have
glacial pace, if at all, until about the cluding anesthesia, antisepsis, and x- been instrumental in industry’s devel-
beginning of the nineteenth century. ray imaging. But until about the time opment of an entire science of im-
That was a time of enormous social of World War II, the guardian moral provement and safety that is now
and intellectual change: the latter syndrome continued to dominate slowly working its way into health
stages of the Enlightenment, the be- health care’s social values, and explic- care. And although it would be hard
to prove conclusively that the two are
related, the striking resemblance be-
Commercial values have served as the principal catalyst tween these commercial values and
the Institute of Medicine’s rules for
for the quality movement in medicine when they have achieving quality—which include
transparency and the free flow of in-
come up against the decidedly noncommercial values that formation, continuous decreases in
waste, and customization based on
medicine has held sacrosanct. patients’ needs and values—argues
strongly for a causal connection.

ginning of the end of slavery, the it concern for quality and safety re- The Value of Quality
spread of democracy and republican- mained strangely muted.
ism, the emergence of the industrial
revolution, and the rapid evolution of
science. Jacobs argues that a major—
Two events that emerged in the
1940s were instrumental in prompt-
ing medicine to take quality and safe-
B oth commercial and guardian en-
terprises are essential in well-
functioning societies: when either has
and perhaps the major—force that ty seriously: the discovery of antibi- pushed the other aside, the result has
drove most of these social changes otics, with their seemingly miracu- generally been disastrous. Consider,
was the progressive shift from the lous power to cure humanity’s tradi- for example, the devastation that has
small-scale exchange of goods and tional scourge, infectious disease, and resulted from total government con-
services (much of it in gift relation- the evolution of improved study de- trol of economies such as in the Sovi-
ship mode) into full-blown commer- signs and statistical methods, which et Union and, more recently, Zim-
cial enterprises. made possible the subsequent devel- babwe; or, conversely, the chaos and
Commerce depended for its suc- opment of quantitative clinical re- destruction that has occurred when
cess on the assertion of its own moral search. The arrival of potent pharma- radical free-market policy has re-
“syndrome,” which consisted exactly ceuticals, plus better ways of docu- placed most major governmental
of the moral values that science need- menting their effectiveness (not to functions, as in the recent history of
ed in order to flourish. In commerce, mention better surgical techniques), Indonesia, Chile, Argentina, and
as in science, the questioning of led to a sweeping epiphany: what South Africa, among other places.
dogma—dissent—became a virtue doctors do actually “works”! Equally Further, the two moral syndromes
rather than a heresy. Likewise, metic- important, most of these dazzling must be held together in tension:
ulous observation, insatiable curiosi- new interventions could be separated they cannot be blended together into
ty, and innovation were prized quali- from the “learned intermediaries”— some entirely new enterprise, nor can
ties rather than distractions; the gen- namely, doctors—who delivered they be rigidly separated. The only vi-
eration of new knowledge was recog- them, which made it easier to give able option then is for the two enter-
nized as a productive investment, them commercial value and to buy prises to develop a symbiotic relation-
rather than a threat; and honesty and and sell them in the marketplace. ship that leaves intact the values char-
transparency became the bedrock of And to be sure, during the past acteristic of each, but at the same
marketplace conduct, for the very thirty years, health care has become at time fosters close, respectful interac-
least as much a business as a profes- tion between them. This is what hap-

22 The Hastings Center


pens, for example, when government such behavior could end up pitting telling how much better off patients,
legislates a goal, such as increased au- physicians and patients against one providers, and everyone else might
tomotive fuel efficiency, but leaves it another as suppliers and customers. be. In fact, the many existing exam-
up to industry to figure out how to ples of syndrome-friendly interac-
accomplish that goal, whether by im- tions that support both better clinical
proving engines, or making vehicles  Policy Implications  outcomes and increased efficiency al-
lighter, or developing some other, en- ready give some cause for optimism.
tirely new strategy.
As things stand now, a complex
and often contradictory mix of
F or it to be successful, health care
reform will need to manage ex-
tremely effectively the tension be-
Thus, pay-for-performance, although
hardly a panacea, honors the princi-
ple of making better clinical “wid-
guardian and commercial moral val- tween guardian and commercial val- gets,” rather than just more clinical
ues is roiling the health care system. ues that currently pushes and pulls “widgets.” Pragmatic clinical trials are
For example, the moral obligation medicine in wildly different direc- beginning to provide valuable infor-
felt by providers to do everything tions. If it fails to do so, we are likely mation on the comparative effective-
possible to meet every patient’s med- to face increases in the fragmenting ness of new and existing interven-
ical needs can be seen as a form of effects of commerce, including in- tions, strengthening further the mar-
guardian “largess” that supports— creases in the damaging effects of riage between effectiveness and effi-
and is supported by—commercial in- conflicts of interest, particularly in ciency. And exploration of the busi-
terest in financial gain, but at the clinical research; worsening of the de- ness case for quality suggests that bet-
same time conflicts with the com- structive drive for “hamster wheel” ter care can save “dark green dol-
mercial values of thrift and efficiency. productivity in clinical practice; and lars”—real, bankable savings, that is,
And the fragmenting effects of com- further distortion of undergraduate, not just the “light green dollars” of
merce on social relationships can re- graduate, and continuing medical ed- potential, on-paper savings.
sult in distressing “buyer beware” sce- ucation under pressures of money Finally, consider patient-centered
narios. Take, for example, the recent- and time—while at the same time we care, a concept that found little sup-
ly proposed system of consumer-dri- could fail to overcome guardian lega- port in medicine over the centuries,
ven care, in which trust in physicians, cies such as inefficiency, uncontrolled but that is now emerging as a core
based on unverifiable assertions largess, and difficulty in responding precept in medical quality improve-
about the cost and quality of individ- to patients’ values and preferences. ment. It seems right that the long-
ual physicians’ services, could be con- But if we’re clever and tough standing and widely honored com-
verted from a purely instrumental enough to build in “moral syndrome- mercial adage “The customer is al-
good into a commodity that would friendly” interaction throughout a re- ways right” is creeping into patient
be bought and sold; a marketplace for formed health system, there’s no care. Who would have guessed?

Connecting American Values with Health Reform 23


The highest and best form of efficiency is the
spontaneous cooperation of a free people.
—Woodrow Wilson

Efficiency
Getting Clear on Our Goals

MARC J. ROBERTS

S
ome major fault lines in the current health reform Defining either static or dynamic efficiency requires us
debate arise out of conflicting notions about the de- to further specify our aims. We do need minimum cost
finition and goals of efficiency. There is, however, a production regardless of our goals. However, as discussed
simple and intuitively appealing concept of efficiency below, we can only decide what to produce (how to be al-
that I believe should be a central virtue of any health re- locatively efficient) once we specify our goals. Dynamic
form effort: To be efficient means to use our resources in efficiency requires a trade-off, too, since the more we
the best possible way to achieve our ends. This makes “effi- spend on research today, the less we have to consume
ciency” an instrumental ideal—a goal whose meaning de- today—even if we are better off tomorrow. Moreover, our
pends on whatever substantive ends we embrace. goals should determine what new products and processes
Economics offers some distinctions that can help us we should try to develop, as well as how to trade current
think about our choices. Consider the distinction econo- consumption against future gains. When it comes to
mists draw between “static”and “dynamic” efficiency. Sta- health policy, two of the most widely used formulations
tic efficiency is a short-run, “at any given moment in of “efficiency” incorporate very strong assumptions about
time” formulation; it requires that a society operates those goals.
within a given production process as defined by the avail-
able technology and organizational systems. Achieving Two Perspectives on Health System Efficiency
static efficiency requires production or technical efficien-
cy (ensuring that goods or services are produced at mini-
mum cost) and allocative efficiency (ensuring that the
right set of goods are produced and distributed to the
P ublic health practitioners often define the goal of effi-
ciency in terms of maximizing the overall or average
health of a target population. As attested to by Web sites
right individuals). Dynamic efficiency looks at the long full of statistics about overall life expectancy, infant mor-
term, but it is not quite so well-defined. It refers to the tality, and so on, much discussion and analysis takes this
rate at which our capacity to produce outputs improves form. More complicated versions of this approach require
over time. Dynamic efficiency requires being efficient in us to develop some complex index—like “Quality Ad-
our use of research and development resources in produc- justed Life Years”—that combines the morbidity and
ing new products and processes. mortality consequences of various diseases. There are
enormous ethical and practical problems in such a task,
Marc J. Roberts, PhD, is professor of political economy and since many important value judgments are subsumed in
health policy at the Harvard School of Public Health, where he the process of index construction. For example, how do
has taught a course on the ethics of public health policy for we value pain relief versus saving lives, or mental health
more than fifteen years.
versus physical health? How do we value saving the young

24 The Hastings Center


versus the old, or the productive ver- Those who advocate for con- sources in nonproductive ways, we
sus the disabled? sumer-driven health care, higher co- have major problems with allocative
This view of efficiency is oriented payments and deductibles, and the efficiency as well.
toward need—toward what experts substitution of savings accounts for Ironically, both the health care
believe will produce the “biggest bang insurance are in the “happiness/de- economics and public health ap-
for the buck” in order to make every- mands” camp. They believe that we proaches to efficiency tend to ignore
one healthy. Historically, the roots of can control costs only if consumers the distribution of gains. Equity, as
this view—now often called cost-ef- compare the benefit of more costly they consider it, is a value that con-
fectiveness analysis—are in engineer- and elaborate care with their poten- flicts with efficiency. But this is an il-
ing and in the use of quantitative tial gains in happiness from, say, legitimate and rhetorical sleight-of-
techniques to improve military oper- more costly and elaborate cars, and hand that seeks to capture the social
ations during and after World War II choose accordingly. legitimacy of “efficiency” for those
(what came to be called “operations In terms of static efficiency, both not concerned with distribution. A
research” and “systems analysis”). In the health/needs and the happiness/ society could surely decide that help-
those cases, the goal to be achieved demands groups favor improved ing those who get less care, suffer
was specified in concrete terms like technical or production efficiency. more, and die younger is especially
“enemy planes shot down.” Both also want to be “allocatively” ef- important, and then ask, “Are we effi-
The “health/needs” camp includes ficient, but they have different views ciently meeting our goals of making
advocates of “effectiveness research,” on what this implies because of their the worst off better off?” Indeed, ad-
who push for increased use of clinical different goals. This is demonstrated vocates of greater justice within the
protocols and drug formularies and
who want to eliminate what they see
as inappropriate (and wasteful) varia- The only way the impending avalanche of health care
tions in patterns of care across the
country. They believe we could get costs can be reduced is if we focus our health care research
more with less if only care was deliv-
ered rationally. on innovations that decrease costs rather than on
By contrast, health care econo-
mists typically define “efficiency” in innovations that drive them up.
terms of satisfying individuals’ desires
to the maximum extent possible. in their conflicting attitudes toward American health care system would
(This implicitly assumes that the ex- fostering generic drugs: the “health” be wise to focus on what I propose to
isting distribution of income is either camp most wants cost-reducing call distributive efficiency, since fund-
acceptable or will be “fixed” by some- changes in practice, while the “happi- ing for improving equity will always
one else). They seek Pareto ness” camp is content with innova- be limited. We must make sure, for
optimality—a state in which no one tion that increases cost as well as per- example, that “safety net” hospitals
person can be made better off with- formance, provided the gains are that disproportionately serve the poor
out someone else being made worse something people will pay for. are every bit as technically efficient as
off. Thus being “better off” is defined other hospitals—which, alas, has not
in terms of each person’s own subjec-  Policy Implications  always been the case.
tive level of well-being. Finally, the biggest health policy
This approach focuses on demand:
giving people what they want in
order to make them happy. It is em-
I n my view, efficiency in terms of
health outcomes has to be a major
concern in U.S. health reform. We
challenge facing most industrial
countries at this moment is enhanc-
ing dynamic efficiency—finding new
bodied in cost-benefit analysis, which have the highest health care costs in ways to treat patients that reduce the
was developed after World War II the world among industrial countries costs of care. Aging societies, with in-
when Congress ordered the Army (between 50 percent and 100 percent creasing chronic disease, will face sig-
Corps of Engineers to limit itself to higher than most) and similar—or nificant cost pressures for many years
projects for which the “benefits ex- worse—health outcomes. With to come. And the citizens of increas-
ceed the costs.” From the beginning, roughly 40 percent of all our costs ingly wealthy and secular societies are
the task was to value a diverse set of going into nonclinical activities (ad- also likely to want more costly health
gains and costs in comparable ways. ministration, sales, paper processing, care over time.
Not surprisingly, these came to be ex- and profits) we clearly could use a The only way the impending
pressed in monetary terms, based on major improvement in technical effi- avalanche of health care costs can be
the value that beneficiaries placed on ciency. And since there is also much reduced is if we focus our health care
various outcomes. evidence that we overuse scarce re- research on innovations that decrease

Connecting American Values with Health Reform 25


costs rather than on innovations that dures) to bundled payments for cal outcomes—is in their interest.
drive them up. To do that, we need to episodes of illness or capitated pay- And only then will our entrepreneurs
create a market for cost-reducing in- ments that cover all of a given per- and scientists have an incentive to de-
novations. And to do that, we need to son’s costs for the year. Only then will velop those cost-reducing innova-
move from fee-for-service payment hospitals and doctors find that effi- tions, thereby really increasing our ef-
(which often encourages the overuse ciency—which research shows, ironi- ficiency where it counts.
of expensive new drugs and proce- cally, also often produces better clini-

26 The Hastings Center


A wise man should consider that health
is the greatest of human blessings.
—Hippocrates

Health
The Value at Stake

ERIKA BLACKSHER

F
ew dispute the need for health care reform in Amer- pact of policies in sectors other than health care, such as
ica. Two problems—access and cost—attract the taxation, agriculture, housing, urban planning, trans-
most commentary, and for good reasons. The ranks portation, and education. Such reforms will not only pro-
of uninsured Americans, which have increased annually duce a healthier nation but also reduce the stark health
for the last six years, are likely to reach 50 million in this inequalities that separate Americans who are better off
economic downturn, and health care expenditures are from those who are worse off.
predicted to top $2.5 trillion in 2009. Both problems are
unsustainable features of American health care. But these Health and Value
problems share company with a third that has gone large-
ly overlooked. Our health system, if it can be so called, is
not designed to produce health. Indeed, health care is but
one determinant of health, and by some measures it is a
T his perspective on health system reform turns on a
value rarely identified, defined, or defended in ex-
plicit terms. That value is health itself. Health is thought
relatively minor one. Despite the trillions spent on med- to be a good in several respects. First, people may value
ical services, the United States ranks poorly on key mea- health because it contributes directly to their sense of
sures of health. For example, according to 2004 World well-being; in this sense, it is an intrinsic good—a good
Health Association data, the United States ranks forty- that people enjoy for itself. But even if people do not con-
sixth in average life expectancy out of 192 nations. sciously appreciate their health when they have it, losing
Addressing this gap in our national health reform de- it will make them aware that they rely on some level of it
bate requires a fundamental reorientation in our thinking to pursue their interests and to act on their plans. Health,
about health care and its relationship to health. Reform in this sense, is also an instrumental good that enables
needs to include measures that will help keep people people to manage and control their lives. Health is also a
healthy and better manage their illnesses should they fall collective social good that can contribute to a nation’s pro-
ill. We should standardize insurance benefits, refocus ser- ductivity and reduce absenteeism and health care costs.
vices on primary care, reward the management and pre- Health may seem too simple an idea to define or too
vention of chronic disease, create information systems obvious a value to defend in a debate over health system
that track patient populations, expand community health reform. Questions abound, however, about how to define
centers. We should also assess (and act on) the health im- and produce it and how to balance it with other values. Is
health an expansive idea that relates to human well-being,
Erika Blacksher, PhD, is a research scholar at The Hastings Cen-
or a narrow idea that relates to bodily function? The
ter and a former Robert Wood Johnson Health and Society World Health Organization defines health as “a state of
Scholar at Columbia University. complete physical, mental and social well-being and not

Connecting American Values with Health Reform 27


merely the absence of disease or infir- gotiate a number of American values freedom expressed in those choices.
mity.” Critics charge that the WHO likely to supply resistance. One Policies that remake these social con-
account is too vague and reduces all source of resistance will be those who ditions—for example, ensuring that
dimensions of well-being to health; view such policies as an infringement everyone has a nearby grocery store
they define health more narrowly as on individual liberty. The precise that sells fresh produce, a primary
the absence of disease. But both ap- meaning of liberty may take slightly care physician, a pharmacy, and safe
proaches involve value judgments different forms, depending on the venues for recreation and social gath-
that are likely to be contentious. different objections. Policies that ban erings—can enhance people’s free-
WHO’s definition requires well-de- products (such as trans fats) or that dom to make healthier choices. So
veloped ideas about the good life; the regulate activities (such as driving some forms of collective action can
narrower, biomedical constructs re- without a seat belt) may be said to in- enhance people’s liberty.
quire consensus on notions such as terfere with individuals’ freedom of That these social conditions are
what counts as normal functioning choice. Others may take aim at gov- often the product of widely endorsed
and what counts as suffering. Still ernment programs and the taxes they public policies suggests that the call
other definitional complexities and entail, based on a principled rejection for personal responsibility should be
accompanied by an awakening of our
sense of shared responsibility. The
Health care is but one determinant of health, and by idea is not foreign to U.S. political
culture; indeed, it seems to be at the
some measures it is a relatively minor one. center of our new president’s philoso-
phy. President Barack Obama has
controversies exist. But no matter of the role of government, save its ac- called for a “new era of responsibility”
how we measure health, the United tivities related to national defense, that makes demands not just of indi-
States compares poorly to other law enforcement, and judicial institu- viduals, but also of families, commu-
wealthy countries and even to some tions that protect individual rights. nities, and society at large. This big-
middle- and low-income countries. These positions share a concern with tent conception of responsibility
While we need not agree on a par- what people are free from and may should be directed at promoting
ticular concept of health in order to find common cause with a second health for all.
agree that we are an unhealthy na- plank of resistance to any robust
tion, how we conceive of health has health equity agenda—the view of  Policy Implications 
implications for how we think about health as individual responsibility. In-
improving it. Because the biomedical
conceptions of health rest on concep-
tions of disease and disability, they
dividuals, not the state, are responsi-
ble for improving their health, and if
they fail at that, it is individuals who
T he social determinants of health
are particularly salient in this era
of chronic disease, whose causes can
run the risk of channeling our collec- must shoulder the consequences. be traced to the conditions in which
tive attention and action toward Of course, everyone knows of peo- we grow up, live, learn, work, and
medical services that respond to dis- ple who have managed, even against play. Health habits related to diet, ex-
ease and disability—and away from great odds, to change deeply in- ercise, and tobacco use make an in-
broader social systems that prevent grained ways of living and improve disputable contribution to the onset
disease and promote health. Univer- their health. But many people don’t and progression of chronic diseases
sal access to timely, high-quality pri- manage that, and members of socioe- and help explain some of the dispro-
mary care certainly would help to im- conomically marginalized and minor- portionate disease burden among
prove health outcomes and reduce ity groups are disproportionately lower socioeconomic groups. But
health inequalities. But even with among those who maintain poor health habits do not explain all of it.
universal coverage, disparities in dis- health habits. This fact should cause Low socioeconomic status itself con-
ease and injury will remain because it us to rethink and reframe the ques- tributes to premature mortality and
takes more than health care to ensure tion of responsibility and how we excess morbidity. Researchers do not
health. For example, medical services think about liberty. The significance yet know which markers of class exert
make a mere 10 to 15 percent contri- of class and race for health habits the most profound influence on
bution to reducing premature death. does not suggest that members of so- health, but low educational attain-
In addition, factors that contribute to cially disadvantaged groups are all ment, low-wage jobs, poor-quality
health include health-related behav- choosing in lockstep; rather, it sug- housing, and polluted and dangerous
iors, genes, and social, economic, and gests that their choices are systemati- neighborhoods, along with the stress
environmental conditions. cally constrained by living, learning, and social isolation these experiences
The pursuit of health equity in and working conditions that can may induce, all plainly play a role.
this political culture will have to ne- limit people’s choices and perhaps the The vagaries associated with being

28 The Hastings Center


poor or near poor exact an especially mended, and some are already being children, by providing income sup-
heavy toll on the health and develop- implemented in states and cities ports, securing nutrition, and enrich-
ment of children, often with lifelong around the country. These interven- ing educational environments and
effects. tions include measures aimed at sev- opportunities. Yet other possible in-
If the organizing principle of eral different levels. Some focus on terventions promote educational at-
health reform is the production and neighborhood conditions: they seek tainment and improve work condi-
the fair distribution of health, then to improve housing stock, create safe tions and benefits for adults. These
we will need to rethink what a health areas for exercise, and enhance the measures cannot guarantee health for
system is. What might such a system food supply (such as by banning all. But they can promote a fair op-
look like and what sort of policies trans fats and by supporting farmers’ portunity for health for all. And that
would it entail? Promising policies markets, for example). Other inter- is a very American value.
and programs have been recom- ventions focus on at-risk families and

Connecting American Values with Health Reform 29


...and the call for Stewardship of the
collective resources…is clear ...
—Thomas Aquinas

Stewardship
What Kind of Society Do We Want?

LEN M. NICHOLS

T
o exercise stewardship, or not—that is the ques- health is to every individual body. Without health no
tion. Why put the point that way? Because one pleasure can be tasted by man; without liberty, no happi-
path leads to an abundant life, and the other is a ness can be enjoyed by society.” What does the right to
dishonest, if elaborate, form of suicide. life mean if one does not also have access to known and
Stewards distinguish themselves first by accepting re- widely available life-preserving and life-enhancing diag-
sponsibility, and then by acting on that responsibility to noses and treatments? How can one meaningfully pursue
preserve, protect, and nurture something precious, any individual definition of happiness if one cannot af-
through recurrent threats, for the purpose of delivering ford essential care for a sick child, a breadwinner, or a dis-
that precious thing to future generations. abled spouse or parent? In short, what is life and happi-
Who may confer and who must accept responsibility ness without health?
for stewardship of our health resources and the health of At the same time, what is happiness if “too much” of
our population? your hard-earned income or wealth is taxed away, even it
Some libertarians today argue that society is a myth, is taxed to pay for the critical needs of others? Especially
that no one has responsibility for the outcome of hun- if “too much” is defined subjectively (as it must be in the
dreds of millions of health-related decisions, and that end), based on one’s personal understanding of the facts?
anyone who asserts such responsibility and tries to act
upon it is both an arrogant tyrant and an existential Crisis and Covenant
threat to the essential freedoms upon which our nation
was founded. Nothing (and no tiny group of argumenta-
tive people) has ever been more profoundly wrong.
Thomas Jefferson, that true student and teacher of lib-
F or an unusual but very helpful way of answering these
questions, put recent work by the Institute of Medi-
cine alongside some ancient teachings in Leviticus, the
erty, amended John Locke’s famous trilogy (life, liberty, third book of the Torah and of the Old Testament in the
and estate) and wrote that all people have an inalienable Christian bible.
right to life, liberty, and the pursuit of happiness. Jeffer- The Institute of Medicine’s 2009 report, America’s
son also wrote: “Liberty is to the collective body, what Uninsured Crisis: Consequences for Health and Health
Care, affirmed and updated its 2002 conclusion that
roughly twenty thousand Americans die every year be-
Len M. Nichols, PhD, directs the Health Policy Program at the cause they do not have access to routine but efficacious
New America Foundation. Previously, he was the vice president
of the Center for Studying Health System Change, a principal re- care because they lack health insurance. This means that
search associate at the Urban Institute, and the senior advisor for over the fifteen years since we stopped debating the Clin-
health policy at the Office of Management and Budget. ton plan for comprehensive health reform, we have lost

30 The Hastings Center


The Gleaners,
by Jean Francois Millet

three hundred thousand of our fellow


citizens to our collective failure to en-
sure coverage for all. No one doubts
that the main reason the vast majori-
ty of the uninsured lack coverage is
cost. That is to say, we effectively ra-
tion care—and life—by income, and
every student of and participant in
our health care system knows it.
Chapter 23, verse 22, of Leviticus
admonishes the landowner at harvest
time to leave a bit of the crop in the
field so that it may be “gleaned” by
the poor and the alien. Later books
written by Moses and by later That is what stewardship is: leaders have to take care to
prophets (as well as the Qu’ran) used
the more frequently taught and re- set rules and make key choices to prevent imbalances that
membered formulation, “widow, or-
phan, and stranger.” Why was feed- would lead to unacceptable outcomes.
ing the hungry such an important ad-
monition? Because otherwise those ing and enriching lives stricken with everyone has the exact same amount
on the fringes of community might illness. Since all of us could be strick- of food. Leviticus expects the
starve, having no established property en with serious illness, since all of us landowner to exercise stewardship
right to food (you had to be an adult could lose our job and our insurance over his resources so that his own self-
male to own land in ancient Pales- tomorrow, all of us are also potential interest is preserved, as well as the
tine)—and preventable starvation “strangers,” which is to say that our fundamental requirements of fellow-
was simply unacceptable. It violated commitment to the covenant is ulti- ship within the community. That is
the sacred covenant with God. Every mately self-interested, as it was in what stewardship is: leaders have to
human being was made in the image biblical times. That does not make it take care to set rules and make key
of God and therefore had the right to less sacred. choices to prevent imbalances that
participate in the life of the commu- At the same time, it is important would lead to unacceptable out-
nity—the right to life. Landowners to read the call for stewardship im- comes, such as some being left out al-
were called to be stewards of their plicit in Leviticus carefully. Leviticus together or the land being over-
own “estate,” and of the fruit of their does not say to bring the poor home worked or abused and losing its pro-
labors (in Locke’s sense), so that no and cook for them; it says, Leave ductive capacity.
one would starve, even those who did some of the harvest in the field for
not share family, tribal, or even reli- them to glean. Our oldest obligations  Policy Implications 
gious connections. Even in America, have always been mutual: it is per-
where social solidarity is nowhere
near prophetic or even European
standards, we have food stamps and
fectly and morally acceptable to ex-
pect personal responsibility from the
beneficiaries of our covenantal
M apping this ancient lesson onto
stewardship requirements for
our health care system seems straight-
food banks. We honor the ancient largess. forward to me. Political, economic,
covenant to feed the hungry in every Leviticus also does not say to leave and health system leaders—the
community. all the food that one poor person “landowners”—must make sure that
Health care has become like food. might want, nor does it admonish our system serves all of us at a basic
It is a unique gift, capable of sustain- the landowner to make sure that level (and not just all Americans, but

Connecting American Values with Health Reform 31


all residents and visitors, if you inter- and reforming payment structures in veloped nations) yet leaving 16 per-
pret “stranger” in the Biblical sense, the Medicare program to realign cent of our population out of the sys-
as I am recommending). At the same provider incentives so that they en- tem (while other developed nations
time, rules and choices must be made gender a far more efficient delivery typically include all of theirs) is prima
so that the system will be sustainable system. The savings from this, plus facie evidence that our system needs a
over time, and thus able to serve all of reducing the current regressive tax fundamental realignment of incen-
us in the future. subsidy for employer-provided health tives and redistribution of access
Those rules include restructuring insurance, should be enough to make rights. Such change simply cannot be
insurance markets to make them our financing and delivery systems afforded, however, unless we also si-
both fairer and more efficient. We sustainable over time. multaneously undertake an effort
should require all insurers to end dis- Changing the system along these akin to the “parting of the waters” to
crimination based on health status lines will likely require constant re- improve the efficiency of our health
and all individuals to purchase insur- evaluation of system performance in care system. This will not be easy, but
ance (or enroll in a public program access, quality, and cost dimensions. the payoff in social cohesion will be
for which they’re eligible). The choic- At the moment, spending 16 percent worth it, and the ancient admonition
es include a sliding scale subsidy of the national gross domestic prod- of stewardship demands no less.
schedule that ensures affordability, uct (almost twice the average in de-

32 The Hastings Center


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