A Health Care Limits Exercise

Adapted from Cultural Maturity: A Guidebook for the Future


Two related inviolable limits are inextricably tied to the health care delivery crisis: the fact of economic limits and the need for a new relationship to life’s ultimate limit, the fact of our mortality. There is also a third limit of a more conceptual sort, namely how familiar ideologies fail to help us make mature decisions. Neither more centralized, managed care structures nor more free market health care approaches will work if we don’t confront these fundamental constraints.

The more complex picture a deep appreciation for health care limits implies quickly gets beyond the current steps that are likely most important in addressing the health care delivery crisis. Short term, we need to make health care more universally available (even if that does increase costs), address inefficiencies wherever we can find them, and curb the more egregious of health care excesses. But there very much is a much larger picture. For now, at least, it is highly informative. And we can’t ignore it for long.

That larger picture greatly expands the challenge, but it also reveals some of the greatest rewards. A good place to see such implications is in the way confronting heath care limits leads to addressing concerns that go beyond health care delivery per se. Confronting health care limits should contribute to increasingly mature and empowered insights regarding not just access to care, but also about what it takes to be healthy, what it means to heal, and, more broadly, the requirements of a healthy society.

A health care limits exercise I’ve done with leaders at the Institute for Creative Development helps illustrate. I give the group I’m working with a budget along with ten patient biographies. The biographies include information not just about age and presenting illnesses, but also about the patient’s family and work history, self-care variables such as smoking and exercise, and more general observations about what the person has done with his or her life. I lock the group in a room for three hours with instructions to come back with a list of how the budget will be spent and justifications for their decisions. I emphasize that the predicament I have put to them is not just some interesting exercise. It is the truth we face if we are not in total denial (and which we face covertly even if we are in denial).

The exercise never fails to prove both agonizing and ultimately enlightening. Participants have to face not just the fact of, in effect, choosing death for others, but also the need to determine on just what bases such decisions should be made. Should they consider not just a person’s disease, but also their age, or perhaps whether they have children who are dependent on them? They also have to confront questions of just what we as humans are capable of—whether certain life-and-death considerations, while perhaps appropriate to a situation, may present moral slippery slopes that will always be too slippery for our human capabilities.

After doing the exercise, the conversation turns inevitably to health care more generally—how we should think of it and where health care dollars are ultimately best spent. Start addressing health care limits and pretty soon we begin examining questions that expand the health care picture dramatically. For example, we might ask,  “Wouldn’t it make sense to spend more of our money on prevention?” And then, “If prenatal care is valuable prevention, what about good nutrition?”  And we can go on.  “If good nutrition is important, what about cleaning up toxic chemicals in the environment?” And if that too is part of health care’s larger picture, what about the effects of poverty, and lack of housing, … and today’s larger crisis of purpose?

All that perhaps takes the systemic analysis too far. But additional important “bridgings,” beyond those that pertain to polar ideological positions and the ultimate polarity of life-versus-death, clearly now come into play: doctor and patient (in how a more empowered doctor/patient relationship has clear advantages when it comes to prevention); mind and body (in the degree that all aspects of the person—physical, psychological, spiritual—play a role in the most effective care); and personal and societal (in the impossibility, ultimately, of separating questions of individual health from those of larger well-being).

Acknowledging economic health care limits leads in the end to rethinking health care fundamentally. It requires of us a more all-the-crayons-in-the-box systemic picture of both health and health care delivery. That increases demands. But it ultimately means a better job of asking the right questions. And for today that is just what the doctor ordered, a fresh, really big-picture look at the whole health care endeavor.