These two pieces are adapted from Cultural Maturity: A Guidebook for the Future.
Health Care Limits:
The current health care delivery crisis presents a particularly good limits-related example, one that for me as a physician touches especially close to home.
We tend to frame the health care delivery crisis as a battle between approaches—such as single-payer versus free-market—and evaluate potential approaches by contrasting solutions used in other countries. But the fact of the matter is that no kind of approach, however and wherever it is applied, will work unless we are willing to more deeply and confront limits. Over the last decade, health care costs in the U.S. have increased at five times the rate of inflation, and there is no natural end in sight. Health care expenditures threaten to bring down health care systems of every sort, all over the world.
Spiraling costs aren’t really anybody’s fault. The dramatically increasing expenditures we see are primarily a product of modern medicine’s great success. Early medical innovations—such as sterile technique and penicillin—were relatively cheap. More recent advances—such as sophisticated diagnostic procedures, exotic new medications, transplant surgeries, and more—have been increasingly expensive, and future advances promise only to get more so. But whatever its cause, this trend of escalating costs obviously can’t continue indefinitely. It threatens not just the future of health care, but also the long term viability of economies.
So how do we effectively address the health care delivery crisis? The answer is straightforward, but it’s not something that we want to look at. Unless we are willing to spend an ever-expanding percentage of national resources on health care, we have no choice but to restrict available medical services—or, if we wish to be more blunt and provocative in our language, we must ration care. And we really have to do it. We can start with getting rid of procedures without demonstrated efficacy. But eventually we will also need to limit the availability of procedures that have real value. This is not just a matter of choice. Given time and ever more expensive future advances, the need to limit even care that provides demonstrable value becomes inescapable.
Rationing care puts before us a whole new order of ethical challenge. At the very 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 with life’s ultimate limit—with death. Medicine has always been about life-and-death decisions. But limiting care demands that we consciously, in effect, choose death—at least in the sense of withholding care that might delay death’s arrival.
In the end, effective health care policy will require a maturity in our relationship with death that has not been necessary—nor, I would argue, within our human capacity—until now.
One of the reasons I like health care delivery as an example is that it so pointedly illustrates how the conundrums we face in confronting ultimate limits are rarely just a product of external circumstances. More ultimately they are about ourselves. The health care delivery crisis is a crisis of resources, but as much it is a moral crisis and a challenge to what we believe. It is, in the end, a product of policies based on outdated ways of thinking—on our ideologies, if you will. The solutions consequently must come from changes in what and how we understand.
I have met few people—and in particular few people involved in political decision-making—who recognize the full implications of the health care delivery crisis. Current efforts at health care reform emphasize providing better coverage for the uninsured, giving greater attention to preventive care, putting medical records in electronic form, and conducting effectiveness studies for medical treatments. These are all good short-term goals. But the savings that might be accrued by these implied cost-cutting measures are much less than most people imagine. Eventually, we must confront more ultimate limits. What doing so asks of us will make other death-related policy issues such as abortion, assisted suicide, and capital punishment look like child’s play.
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 the questions we need to ask if future heath care decisions are to serve us. The courage to ask such questions also supports the new and deeper—complex and wise—understandings that the future requires more generally.
In Chapter Four, with this chapter’s big-picture limits-related reflections then under our belts, I will return to the health care delivery crisis. There I will describe how grappling with health care limits can result not just in more intelligent decisions, but also in a more vital and life-affirming relationship with the whole health care endeavor.
The Future of Medicine (and Health Care More generally):
Essential leadership tasks: Health care professionals need to ask deeply what it means to offer quality, universally available care in the face of inescapable economic limits. They also need to provide leadership in helping us think much more expansively and creatively about what the enhancing of health ultimately entails.
My own professional background has meant that health care questions have already received considerable attention—in particular with Chapter Fours look at implications of the heath care delivery crisis and Chapter Ten’s look at how our understanding of the body has changed through history. I will keep further reflections brief and primarily of a summary nature.
The basic answer to health care’s Question of Referent is straightforward: Health care is about keeping people healthy. But it is also true, as I’ve observed, that how we have thought about health and healing has not always been the same. I’ve described how, with each cultural stage, we have come to view not just the human body, but health care’s task in significantly different ways. I also described how the assumptions of modern “scientific medicine” are consistent with what we see in other spheres with the most recent, Late-Axis stage in this sequence.
Two changes have been especially critical to what we witness today. In keeping with Modern Age machine model thinking, we have come increasing to view health care as the fixing of broken anatomy and physiology. And, particularly over the last century, we have seen significant changes in the status afforded the practice of medicine and, with this, in how we think about medicine’s role in culture. It was not long ago that surgury was commonly done by barbers. We have come increasingly not just to better respect medicine, but also to mythologize it.
In part, this elevated status has been a product of major successes. Particularly important were successes that followed from the germ theory of medicine—first, the transforming application of sterile technique, and later, the discovery of antibiotics. And certainly more recent successes such as the growing prevalence of organ transplantation and new insights coming from the biotechnology revolution have also contributed. But this newly elevated status has also reflected how, with the Modern Age, we’ve come to mythologize any activity we associate with science. As medicine has more and more been thought of as a scientific pursuit, we’ve gradually come to describe its cultural role in grand heroic terms. Health care has come to be about defeating death and disease—and, as I’ve observed, this essentially at any cost.
With many of the Cultural Maturity–related health care challenges I’ve made reference to, we have made at least solid first steps. We haven’t progressed as far with confronting death directly as the effective addressing of spiraling health care costs will require. But health care professionals today are gradually becoming more comfortable speaking about death with their patients, and hospice care has become an increasingly respected aspect of health care’s contribution. And the doctor/patient relationship is one of the places where the value of more Whole-Person leadership is being most recognized. We increasingly appreciate the importance of physicians being able to listen to their patients as well as write orders, and patients are coming both to take greater responsibility for their care and to be better informed so that they can do so effectively.
We are also seeing at least the beginnings of the kind of rethinking of what health care’s big picture that I made reference to with the rationing care exercise in Chapter Four. Certainly we are coming to better recognize the value of prevention. This includes preventive screening, but also, and at least as important, making good lifestyle choices—eating healthy foods, getting adequate sleep and exercise. We are also better appreciating the roles that psychological factors such as stress play in personal well-being. And we are beginning to better recognize that a healthy environment is key to health—both a healthy physical environment (we are getting better, for example, at seeing the health dangers presented by environmental pollutants) and a healthy social environment (for example, we are beginning to better appreciate poverty’s major role as a risk factor for diseases of almost every sort).
The kind of deeper thinking about the mechanisms of health and healing I made reference to in Chapter Nine is more rare, and often when intriguing questions are raised, polar traps distort conclusions. But here, too, we see at least beginning headway. In particular, discoveries derived from attempts to tease out the complex workings of the immune system (often spurred by the AIDS epidemic), along with new insights from efforts to understand the genetic underpinning of disease, have forced medicine to think about bodily processes in more dynamic ways.
The world of health care, too, has its Transitional Absurdities. More often than not, modern medicine has continued to apply a “great machine” model to bodily functioning, even while the best of thinking in other spheres has learned to leave such antiquated thinking in the past. (My medical training, while the best available, was in effect the training of a highly educated plumber or electrician.) Particularly striking is our ability to celebrate each new, more expensive medical advance while rarely raising the question of whether the advance is something that we can ultimately afford. Such denial is understandable given the new relationship to death that effectively confronting health care limits will entail. But it has stopped being helpful, or even really sane.