The emotional vitriol we’ve witnessed in recent years in the health care delivery debate has startled both politicians and the press. In fact it was totally predicted. Effective and affordable health care in times ahead will require a whole new kind of maturity in our relationship to life’s ultimate limit—to the fact of death.
I’ve written about the looming conundrum addressing this limit presents for years, but we may just now be ready to confront the challenge. As a physician it is a challenge that touches especially close to home. It applies equally whatever a county’s approach to health care delivery. The health care delivery crisis is not just a U.S. crisis. In time it will confront even the countries that now have the most enlightened of policies.
Health care expenditures are spiraling uncontrollably—for everyone. Over the last decade, health care costs have increased at five times the rate of inflation. And there is no natural end in sight. While inefficiencies and excesses play a role, in the end, escalating costs are a product primarily of modern medicine’s great success. Early innovations—like sterile technique and penicillin—were relatively cheap. More recent advances—sophisticated diagnostic procedures, exotic new medications, transplant surgeries, and more—are increasingly expensive and promise only to get more so.
Escalating costs clearly can’t continue indefinitely. Increasingly they will threaten not just medical care, but the health of economies. But containing costs will require more that just austerity. Unless we are willing to spend an ever-expanding percentage of national resources on health, we have no choice but to restrict health care spending. Ultimately, this means in some way limiting available medical services—or, if we wish to be more blunt and provocative in our language, it means that we must in some way ration care. Initially this would involve restricting treatments of questionable efficacy — which we are already beginning to do. But eventually it would need to involve restricting care that could be effective, but which is simply beyond what we can afford.
Restricting care in this way put before us a whole new order of ethical challenge. At the least, not providing care when we have effective care to offer calls into question modern medicine’s defeat-disease-at-any-cost heroic mythology. But the challenge is deeper. Restricting care demands a new relationship to the most taboo of topics: our human mortality. Medicine has always been about life-and-death decisions. But limiting care demands in effect the conscious choosing of death—at least in the sense of withholding care that might delay death’s arrival. Good long-term health care polity will require a maturety in our relationship with death not before necessary, nor, I would argue, within our human capacity to handle.
I have met few people—and particularly in the political sphere—who recognize the full implications of the health care delivery crisis. Current efforts at health care reform emphasize better covering the uninsured, giving greater attention to preventive care, putting medical records in electronic form, and effectiveness studies of medical treatments. These are all good short-term goals. But savings that might be accrued by implied cost-cutting measures are much less than most imagine. Eventually we must confront more ultimate limits. What doing so asks of us will make the controversies around more limited death-related issues such as abortion, assisted suicide, and capital punishment look like child’s play.
I argue in my writings (See Cultural Maturity: A Guidebook for the Future) that the rewards for confronting limits go beyond just avoiding the unpleasant consequences of denial; confronting inviolable limits in the end reveals options not otherwise visible. Health care limits provide a good example. 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. 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? For today, isn’t that is just what the doctor ordered—a fresh, really big-picture look at the whole health care endeavor?
The questions presented by confronting health care limits are not just harder than we yet recognize, they are harder than we have been capable of recognizing up to this point in our development as a species. But they are also the necessary questions if our efforts are to be helpful. The courage to ask them will reveal essential new options. It will also support the new and deeper—complex and wise—understandings the future requires more generally.