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

This essay appears in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

To exercise stewardship, or not—that is the question. Why put the point that way? Because one path leads to an abundant life, and the other is a dishonest, if elaborate, form of suicide.

Stewards distinguish themselves first by accepting responsibility, and then by acting on that responsibility to preserve, protect, and nurture something precious, through recurrent threats, for the purpose of delivering that precious thing to future generations.

Who may confer and who must accept responsibility for stewardship of our health resources and the health of our population?

Some libertarians today argue that society is a myth, that no one has responsibility for the outcome of hundreds of millions of health-related decisions, and that anyone who asserts such responsibility and tries to act upon it is both an arrogant tyrant and an existential threat to the essential freedoms upon which our nation was founded. Nothing (and no tiny group of argumentative people) has ever been more profoundly wrong.

Thomas Jefferson, that true student and teacher of liberty, amended John Locke’s famous trilogy (life, liberty, and estate) and wrote that all people have an inalienable right to life, liberty, and the pursuit of happiness. Jefferson also wrote: “Liberty is to the collective body, what health is to every individual body. Without health no pleasure can be tasted by man; without liberty, no happiness can be enjoyed by society.” What does the right to life mean if one does not also have access to known and widely available life-preserving and life-enhancing diagnoses and treatments? How can one meaningfully pursue any individual definition of happiness if one cannot afford essential care for a sick child, a breadwinner, or a disabled spouse or parent? In short, what is life and happiness without health?

At the same time, what is happiness if “too much” of your hard-earned income or wealth is taxed away, even it is taxed to pay for the critical needs of others? Especially if “too much” is defined subjectively (as it must be in the end), based on one’s personal understanding of the facts?

Crisis and Covenant

For an unusual but very helpful way of answering these questions, put recent work by the Institute of Medicine alongside some ancient teachings in Leviticus, the third book of the Torah and of the Old Testament in the Christian bible.

The Institute of Medicine’s 2009 report, America’s Uninsured Crisis: Consequences for Health and Health Care, affirmed and updated its 2002 conclusion that roughly twenty thousand Americans die every year because they do not have access to routine but efficacious care because they lack health insurance. This means that over the fifteen years since we stopped debating the Clinton plan for comprehensive health reform, we have lost three hundred thousand of our fellow citizens to our collective failure to ensure coverage for all. No one doubts that the main reason the vast majority of the uninsured lack coverage is cost. That is to say, we effectively ration 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 prophets (as well as the Qu’ran) used the more frequently taught and remembered formulation, “widow, or¬phan, and stranger.” Why was feed¬ing the hungry such an important ad-monition? Because otherwise those on the fringes of community might starve, having no established property right to food (you had to be an adult male to own land in ancient Palestine)—and preventable starvation was simply unacceptable. It violated the sacred covenant with God. Every human being was made in the image of God and therefore had the right to participate in the life of the community—the right to life. Landowners were called to be stewards of their own “estate,” and of the fruit of their labors (in Locke’s sense), so that no one would starve, even those who did not share family, tribal, or even reli-gious connections. Even in America, where social solidarity is nowhere near prophetic or even European standards, we have food stamps and food banks. We honor the ancient covenant to feed the hungry in every community.

Health care has become like food. It is a unique gift, capable of sustaining and enriching lives stricken with illness. Since all of us could be stricken with serious illness, since all of us could lose our job and our insurance tomorrow, all of us are also potential “strangers,” which is to say that our commitment to the covenant is ulti-mately self-interested, as it was in biblical times. That does not make it less sacred.

At the same time, it is important to read the call for stewardship implicit in Leviticus carefully. Leviticus does not say to bring the poor home and cook for them; it says, Leave some of the harvest in the field for them to glean. Our oldest obligations have always been mutual: it is perfectly and morally acceptable to expect personal responsibility from the beneficiaries of our covenantal largess.

Leviticus also does not say to leave all the food that one poor person might want, nor does it admonish the landowner to make sure that everyone has the exact same amount of food. Leviticus expects the landowner to exercise stewardship over his resources so that his own self-interest is preserved, as well as the fundamental requirements of fellowship within the community. That is what stewardship is: leaders have to take care to set rules and make key choices to prevent imbalances that would lead to unacceptable outcomes, such as some being left out altogether or the land being overworked or abused and losing its productive capacity.

Policy Implications

Mapping this ancient lesson onto stewardship requirements for our health care system seems straightforward to me. Political, economic, and health system leaders — the “landowners” — must make sure that our system serves all of us at a basic level (and not just all Americans, but all residents and visitors, if you interpret “stranger” in the Biblical sense, as I am recommending). At the same time, rules and choices must be made so that the system will be sustainable over time, and thus able to serve all of us in the future.

Those rules include restructuring insurance markets to make them both fairer and more efficient. We should require all insurers to end discrimination based on health status and all individuals to purchase insurance (or enroll in a public program for which they’re eligible). The choices include a sliding scale subsidy schedule that ensures affordability, and reforming payment structures in the Medicare program to realign provider incentives so that they engender a far more efficient delivery system. The savings from this, plus reducing the current regressive tax subsidy for employer-provided health insurance, should be enough to make our financing and delivery systems sustainable over time.

Changing the system along these lines will likely require constant reevaluation of system performance in access, quality, and cost dimensions. At the moment, spending 16 percent of the national gross domestic product (almost twice the average in developed nations) yet leaving 16 percent of our population out of the system (while other developed nations typically include all of theirs) is prima facie evidence that our system needs a fundamental realignment of incentives and redistribution of access rights. Such change simply cannot be afforded, however, unless we also simultaneously undertake an effort akin to the “parting of the waters” to improve the efficiency of our health care system. This will not be easy, but the payoff in social cohesion will be worth it, and the ancient admonition of stewardship demands no less.

Len M. Nichols, PhD, directs the Health Policy Program at the New America Foundation. Previously, he was the vice president of the Center for Studying Health System Change, a principal research associate at the Urban Institute, and the senior advisor for health policy at the Office of Management and Budget.

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

This essay appears in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

Few dispute the need for health care reform in America. Two problems—access and cost—attract the most commentary, and for good reasons. The ranks of uninsured Americans, which have increased annually for the last six years, are likely to reach 50 million in this economic downturn, and health care expenditures are predicted to top $2.5 trillion in 2009. Both problems are unsustainable features of American health care. But these problems share company with a third that has gone largely 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 relatively minor one. Despite the trillions spent on medical services, the United States ranks poorly on key measures of health. For example, according to 2004 World Health Association data, the United States ranks forty-sixth in average life expectancy out of 192 nations.

Addressing this gap in our national health reform debate requires a fundamental reorientation in our thinking about health care and its relationship to health. Reform needs to include measures that will help keep people healthy and better manage their illnesses should they fall ill. We should standardize insurance benefits, refocus services on primary care, reward the management and prevention of chronic disease, create information systems that track patient populations, expand community health centers. We should also assess (and act on) the health impact of policies in sectors other than health care, such as taxation, agriculture, housing, urban planning, transportation, and education. Such reforms will not only produce a healthier nation but also reduce the stark health inequalities that separate Americans who are better off from those who are worse off.

Health and Value

This perspective on health system reform turns on a value rarely identified, defined, or defended in explicit terms. That value is health itself. Health is thought to be a good in several respects. First, people may value health because it contributes directly to their sense of well-being; in this sense, it is an intrinsic good—a good that people enjoy for itself. But even if people do not consciously appreciate their health when they have it, losing it will make them aware that they rely on some level of it to pursue their interests and to act on their plans. Health, in this sense, is also an instrumental good that enables people to manage and control their lives. Health is also a collective social good that can contribute to a nation’s productivity and reduce absenteeism and health care costs.

Health may seem too simple an idea to define or too obvious a value to defend in a debate over health system reform. Questions abound, however, about how to define and produce it and how to balance it with other values. Is health an expansive idea that relates to human well-being, or a narrow idea that relates to bodily function? The World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Critics charge that the WHO account is too vague and reduces all dimensions of well-being to health; they define health more narrowly as the absence of disease. But both approaches involve value judgments that are likely to be contentious. WHO’s definition requires well-developed ideas about the good life; the narrower, biomedical constructs require consensus on notions such as what counts as normal functioning and what counts as suffering. Still other definitional complexities and controversies exist. But no matter how we measure health, the United States compares poorly to other wealthy countries and even to some middle- and low-income countries.

While we need not agree on a particular concept of health in order to agree that we are an unhealthy nation, how we conceive of health has implications for how we think about improving it. Because the biomedical conceptions of health rest on conceptions of disease and disability, they run the risk of channeling our collective attention and action toward medical services that respond to disease and disability—and away from broader social systems that prevent disease and promote health. Universal access to timely, high-quality primary care certainly would help to improve health outcomes and reduce health inequalities. But even with universal coverage, disparities in disease and injury will remain because it takes more than health care to ensure health. For example, medical services make a mere 10 to 15 percent contribution to reducing premature death. In addition, factors that contribute to health include health-related behaviors, genes, and social, economic, and environmental conditions.

The pursuit of health equity in this political culture will have to negotiate a number of American values likely to supply resistance. One source of resistance will be those who view such policies as an infringement on individual liberty. The precise meaning of liberty may take slightly different forms, depending on the different objections. Policies that ban products (such as trans fats) or that regulate activities (such as driving without a seat belt) may be said to interfere with individuals’ freedom of choice. Others may take aim at government programs and the taxes they entail, based on a principled rejection of the role of government, save its activities related to national defense, law enforcement, and judicial institutions that protect individual rights. These positions share a concern with what people are free from and may find common cause with a second plank of resistance to any robust health equity agenda—the view of health as individual responsibility. Individuals, not the state, are responsible for improving their health, and if they fail at that, it is individuals who must shoulder the consequences.

Of course, everyone knows of people who have managed, even against great odds, to change deeply ingrained ways of living and improve their health. But many people don’t manage that, and members of socioeconomically marginalized and minority groups are disproportionately among those who maintain poor health habits. This fact should cause us to rethink and reframe the question of responsibility and how we think about liberty. The significance of class and race for health habits does not suggest that members of socially disadvantaged groups are all choosing in lockstep; rather, it suggests that their choices are systematically constrained by living, learning, and working conditions that can limit people’s choices and perhaps the freedom expressed in those choices. Policies that remake these social conditions—for example, ensuring that everyone has a nearby grocery store that sells fresh produce, a primary care physician, a pharmacy, and safe venues for recreation and social gatherings—can enhance people’s freedom to make healthier choices. So some forms of collective action can enhance people’s liberty.

That these social conditions are often the product of widely endorsed public policies suggests that the call for personal responsibility should be accompanied by an awakening of our sense of shared responsibility. The idea is not foreign to U.S. political culture; indeed, it seems to be at the center of our new president’s philosophy. President Barack Obama has called for a “new era of responsibility” that makes demands not just of individuals, but also of families, communities, and society at large. This big-tent conception of responsibility should be directed at promoting health for all.

Policy Implications

The social determinants of health are particularly salient in this era of chronic disease, whose causes can be traced to the conditions in which we grow up, live, learn, work, and play. Health habits related to diet, exercise, and tobacco use make an indisputable contribution to the onset and progression of chronic diseases and help explain some of the disproportionate disease burden among lower socioeconomic groups. But health habits do not explain all of it. Low socioeconomic status itself contributes to premature mortality and excess morbidity. Researchers do not yet know which markers of class exert the most profound influence on health, but low educational attainment, low-wage jobs, poor-quality housing, and polluted and dangerous neighborhoods, along with the stress and social isolation these experiences may induce, all plainly play a role. The vagaries associated with being poor or near poor exact an especially heavy toll on the health and development of children, often with lifelong effects.

If the organizing principle of health reform is the production and the fair distribution of health, then we will need to rethink what a health system is. What might such a system look like and what sort of policies would it entail? Promising policies and programs have been recommended, and some are already being implemented in states and cities around the country. These interventions include measures aimed at several different levels. Some focus on neighborhood conditions: they seek to improve housing stock, create safe areas for exercise, and enhance the food supply (such as by banning trans fats and by supporting farmers’ markets, for example). Other interventions focus on at-risk families and children, by providing income supports, securing nutrition, and enriching educational environments and opportunities. Yet other possible interventions promote educational attainment and improve work conditions and benefits for adults. These measures cannot guarantee health for all. But they can promote a fair opportunity for health for all. And that is a very American value.

Erika Blacksher, PhD, is a research scholar at The Hastings Center and a former Robert Wood Johnson Health and Society Scholar at Columbia University.

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

This essay appears in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

Some major fault lines in the current health reform debate arise out of conflicting notions about the definition and goals of efficiency. There is, however, a simple and intuitively appealing concept of efficiency that I believe should be a central virtue of any health reform effort: To be efficient means to use our resources in the best possible way to achieve our ends. This makes “efficiency” an instrumental ideal—a goal whose meaning depends on whatever substantive ends we embrace.

Economics offers some distinctions that can help us think about our choices. Consider the distinction economists draw between “static”and “dynamic” efficiency. Static efficiency is a short-run, “at any given moment in time” formulation; it requires that a society operates within a given production process as defined by the available technology and organizational systems. Achieving static efficiency requires production or technical efficiency (ensuring that goods or services are produced at minimum cost) and allocative efficiency (ensuring that the right set of goods are produced and distributed to the right individuals). Dynamic efficiency looks at the long term, but it is not quite so well-defined. It refers to the rate at which our capacity to produce outputs improves over time. Dynamic efficiency requires being efficient in our use of research and development resources in producing new products and processes.

Defining either static or dynamic efficiency requires us to further specify our aims. We do need minimum cost production regardless of our goals. However, as discussed below, we can only decide what to produce (how to be allocatively efficient) once we specify our goals. Dynamic efficiency requires a trade-off, too, since the more we spend on research today, the less we have to consume today—even if we are better off tomorrow. Moreover, our goals should determine what new products and processes we should try to develop, as well as how to trade current consumption against future gains. When it comes to health policy, two of the most widely used formulations of “efficiency” incorporate very strong assumptions about those goals.

Two Perspectives on Health System Efficiency

Public health practitioners often define the goal of efficiency in terms of maximizing the overall or average health of a target population. As attested to by Web sites full of statistics about overall life expectancy, infant mortality, and so on, much discussion and analysis takes this form. More complicated versions of this approach require us to develop some complex index—like “Quality Adjusted Life Years”—that combines the morbidity and mortality consequences of various diseases. There are enormous ethical and practical problems in such a task, since many important value judgments are subsumed in the process of index construction. For example, how do we value pain relief versus saving lives, or mental health versus physical health? How do we value saving the young versus the old, or the productive versus the disabled?
This view of efficiency is oriented toward need—toward what experts believe will produce the “biggest bang for the buck” in order to make everyone healthy. Historically, the roots of this view—now often called cost-effectiveness analysis—are in engineering and in the use of quantitative techniques to improve military operations during and after World War II (what came to be called “operations research” and “systems analysis”). In those cases, the goal to be achieved was specified in concrete terms like “enemy planes shot down.”

The “health/needs” camp includes advocates of “effectiveness research,” who push for increased use of clinical protocols and drug formularies and who want to eliminate what they see as inappropriate (and wasteful) variations in patterns of care across the country. They believe we could get more with less if only care was delivered rationally.

By contrast, health care economists typically define “efficiency” in terms of satisfying individuals’ desires to the maximum extent possible. (This implicitly assumes that the existing distribution of income is either acceptable or will be “fixed” by someone else). They seek Pareto optimality – a state in which no one person can be made better off without someone else being made worse off. Thus being “better off ” is defined in terms of each person’s own subjective level of well-being.

This approach focuses on demand: giving people what they want in order to make them happy. It is embodied in cost-benefit analysis, which was developed after World War II when Congress ordered the Army Corps of Engineers to limit itself to projects for which the “benefits exceed the costs.” From the beginning, the task was to value a diverse set of gains and costs in comparable ways. Not surprisingly, these came to be expressed in monetary terms, based on the value that beneficiaries placed on various outcomes.

Those who advocate for consumer-driven health care, higher copayments and deductibles, and the substitution of savings accounts for insurance are in the “happiness/demands” camp. They believe that we can control costs only if consumers compare the benefit of more costly and elaborate care with their potential gains in happiness from, say, more costly and elaborate cars, and choose accordingly.

In terms of static efficiency, both the health/needs and the happiness/demands groups favor improved technical or production efficiency. Both also want to be “allocatively” efficient, but they have different views on what this implies because of their different goals. This is demonstrated in their conflicting attitudes toward fostering generic drugs: the “health” camp most wants cost-reducing changes in practice, while the “happiness” camp is content with innovation that increases cost as well as performance, provided the gains are something people will pay for.

Policy Implications

In my view, efficiency in terms of health outcomes has to be a major concern in U.S. health reform. We have the highest health care costs in the world among industrial countries (between 50 percent and 100 percent higher than most) and similar—or worse—health outcomes. With roughly 40 percent of all our costs going into nonclinical activities (administration, sales, paper processing, and profits) we clearly could use a major improvement in technical efficiency. And since there is also much evidence that we overuse scarce resources resources in nonproductive ways, we have major problems with allocative efficiency as well.

Ironically, both the health care economics and public health approaches to efficiency tend to ignore the distribution of gains. Equity, as they consider it, is a value that conflicts with efficiency. But this is an illegitimate and rhetorical sleight-of-hand that seeks to capture the social legitimacy of “efficiency” for those not concerned with distribution. A society could surely decide that helping those who get less care, suffer more, and die younger is especially important, and then ask, “Are we efficiently meeting our goals of making the worst off better off?” Indeed, advocates of greater justice within the American health care system would be wise to focus on what I propose to call distributive efficiency, since funding for improving equity will always be limited. We must make sure, for example, that “safety net” hospitals that disproportionately serve the poor are every bit as technically efficient as other hospitals—which, alas, has not always been the case.

Finally, the biggest health policy challenge facing most industrial countries at this moment is enhancing dynamic efficiency—finding new ways to treat patients that reduce the costs of care. Aging societies, with increasing chronic disease, will face significant cost pressures for many years to come. And the citizens of increasingly wealthy and secular societies are also likely to want more costly health care over time.

The only way the impending avalanche of health care costs can be reduced is if we focus our health care research on innovations that decrease costs rather than on innovations that drive them up. To do that, we need to create a market for cost-reducing innovations. And to do that, we need to move from fee-for-service payment (which often encourages the overuse of expensive new drugs and procedures) to bundled payments for episodes of illness or capitated payments that cover all of a given person’s costs for the year. Only then will hospitals and doctors find that efficiency—which research shows, ironically, also often produces better clinical outcomes—is in their interest. And only then will our entrepreneurs and scientists have an incentive to develop those cost-reducing innovations, thereby really increasing our efficiency where it counts.

Marc J. Roberts, PhD, is professor of political economy and health policy at the Harvard School of Public Health, where he has taught a course on the ethics of public health policy for more than fifteen years.

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

This essay appears in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

A movement has emerged within health care over the past several decades that sees quality as the combined and unceasing efforts of everyone involved in health care—professionals, patients and their families, researchers, payers, planners, and educators—to make the changes that will lead to better outcomes, better system performance, and better professional development; in other words, better health, better care, and better learning. This sweeping view recognizes that the pursuit of quality and safety is a dynamic process, not a static and narrowly focused endpoint. People associated with the quality movement accept this pursuit as both a moral responsibility and a serious applied science. They also believe unequivocally that everyone in health care has two jobs when they go to work every day: to provide care, and to make it better—a view that is entirely congruent with the idea that “unceasing movement toward new levels of performance” lies at the very heart of professionalism.

A movement has emerged within health care over the past several decades that sees quality as the combined and unceasing efforts of everyone involved in health care—professionals, patients and their families, researchers, payers, planners, and educators—to make the changes that will lead to better outcomes, better system performance, and better professional development; in other words, better health, better care, and better learning. This sweeping view recognizes that the pursuit of quality and safety is a dynamic process, not a static and narrowly focused endpoint. People associated with the quality movement accept this pursuit as both a moral responsibility and a serious applied science. They also believe unequivocally that everyone in health care has two jobs when they go to work every day: to provide care, and to make it better—a view that is entirely congruent with the idea that “unceasing movement toward new levels of performance” lies at the very heart of professionalism.

Several centuries ago, the widespread adoption of commercial values arguably paved the way for the flowering of science. This essay explores the seemingly unlikely proposition that commercial values have also served as the principal catalyst for the quality movement in medicine when they have come up against the decidedly noncommercial values that medicine has held sacrosanct. Improving the quality of health care is likely to be crucial in the success of health care reform, in part because, like science, improvements in quality can bring benefits that serve as a powerful counterweight to the potentially corrosive effects of commerce on professional and social relationships.

Guardians and Gifts, Science and Commerce

Medicine has historically shunned commerce. Until quite recently, for example, it was not acceptable for doctors and hospitals to advertise. The admonition to “shun trading” is a key element in what the scholar and social critic Jane Jacobs has called the “guardian moral syndrome”—a code of tightly linked moral values that governs one of the two systems of human survival, “taking” (the other being “trading”). In public life, the guardian moral syndrome, which includes the exertion of prowess, adherence to tradition, and the dispersing of largess, is expressed most clearly in government, but also in the military and religion—all of which support themselves through the taking of taxes, tithes, and territory.

Since healers were initially members of a priesthood, it should not be surprising that from its beginnings, health care was essentially a creature of the guardian moral syndrome. Of course, like everyone else, healers need to put bread on the table. But since they neither taxed nor tithed, they were forced to engage in trading. Until about fifty years ago, however, they did so on a limited scale; to a substantial degree, they relied instead on nonfinancial rewards from the “gift relationships” inherent in medical practice. That is, they relied on deferred and uncertain (but ultimately increased) rewards offered in response to their gifts of care and healing. Rather than devoting themselves to the immediate, calculated exchange that defines commerce (such as contracts, investment, capital, and interest), healers felt themselves to be rewarded through their high social status, enormous respect, and great professional autonomy.

The underlying moral values of health care in the West changed at a glacial pace, if at all, until about the beginning of the nineteenth century. That was a time of enormous social and intellectual change: the latter stages of the Enlightenment, the beginning of the end of slavery, the spread of democracy and republicanism, the emergence of the industrial revolution, and the rapid evolution of science. Jacobs argues that a major— and perhaps the major—force that drove most of these social changes was the progressive shift from the small-scale exchange of goods and services (much of it in gift relationship mode) into full-blown commercial enterprises.

Commerce depended for its success on the assertion of its own moral “syndrome,” which consisted exactly of the moral values that science needed in order to flourish. In commerce, as in science, the questioning of dogma—dissent—became a virtue rather than a heresy. Likewise, meticulous observation, insatiable curiosity, and innovation were prized qualities rather than distractions; the generation of new knowledge was recognized as a productive investment, rather than a threat; and honesty and transparency became the bedrock of marketplace conduct, for the very concept of money rests entirely on trust.

Medicine Becomes a Commodity

The scientific awakening slowly made its way into medicine during the nineteenth century, leading to many new, more rational, and improved ways to care for patients, including anesthesia, antisepsis, and x-ray imaging. But until about the time of World War II, the guardian moral syndrome continued to dominate health care’s social values, and explicit concern for quality and safety remained strangely muted.

Two events that emerged in the 1940s were instrumental in prompting medicine to take quality and safety seriously: the discovery of antibiotics, with their seemingly miraculous power to cure humanity’s traditional scourge, infectious disease, and the evolution of improved study designs and statistical methods, which made possible the subsequent development of quantitative clinical research. The arrival of potent pharmaceuticals, plus better ways of documenting their effectiveness (not to mention better surgical techniques), led to a sweeping epiphany: what doctors do actually “works”! Equally important, most of these dazzling new interventions could be separated from the “learned intermediaries”— namely, doctors—who delivered them, which made it easier to give them commercial value and to buy and sell them in the marketplace.

And to be sure, during the past thirty years, health care has become at least as much a business as a profession: patients are now considered “customers,” doctors and hospitals advertise product lines, and medical insurance companies consider money spent on clinical care to be the “loss ratio.” The preoccupation with quality and safety in health care has emerged exactly in parallel with this surge in medical commercialism. The commercial values of comfort, industriousness, thrift, and efficiency have been instrumental in industry’s development of an entire science of improvement and safety that is now slowly working its way into health care. And although it would be hard to prove conclusively that the two are related, the striking resemblance between these commercial values and the Institute of Medicine’s rules for achieving quality—which include transparency and the free flow of information, continuous decreases in waste, and customization based on patients’ needs and values—argues strongly for a causal connection.

The Value of Quality

Both commercial and guardian enterprises are essential in well-functioning societies: when either has pushed the other aside, the result has generally been disastrous. Consider, for example, the devastation that has resulted from total government control of economies such as in the Soviet Union and, more recently, Zimbabwe; or, conversely, the chaos and destruction that has occurred when radical free-market policy has replaced most major governmental functions, as in the recent history of Indonesia, Chile, Argentina, and South Africa, among other places. Further, the two moral syndromes must be held together in tension: they cannot be blended together into some entirely new enterprise, nor can they be rigidly separated. The only viable option then is for the two enterprises to develop a symbiotic relationship that leaves intact the values characteristic of each, but at the same time fosters close, respectful interaction between them. This is what happens, for example, when government legislates a goal, such as increased automotive fuel efficiency, but leaves it up to industry to figure out how to accomplish that goal, whether by improving engines, or making vehicles lighter, or developing some other, entirely new strategy.

As things stand now, a complex and often contradictory mix of guardian and commercial moral values is roiling the health care system. For example, the moral obligation felt by providers to do everything possible to meet every patient’s medical needs can be seen as a form of guardian “largess” that supports— and is supported by—commercial interest in financial gain, but at the same time conflicts with the commercial values of thrift and efficiency. And the fragmenting effects of commerce on social relationships can result in distressing “buyer beware” scenarios. Take, for example, the recently proposed system of consumer-driven care, in which trust in physicians, based on unverifiable assertions about the cost and quality of individual physicians’ services, could be converted from a purely instrumental good into a commodity that would be bought and sold; a marketplace for such behavior could end up pitting physicians and patients against one another as suppliers and customers.

Policy Implications

For it to be successful, health care reform will need to manage extremely effectively the tension between guardian and commercial values that currently pushes and pulls medicine in wildly different directions. If it fails to do so, we are likely to face increases in the fragmenting effects of commerce, including increases in the damaging effects of conflicts of interest, particularly in clinical research; worsening of the destructive drive for “hamster wheel” productivity in clinical practice; and further distortion of undergraduate, graduate, and continuing medical education under pressures of money and time—while at the same time we could fail to overcome guardian legacies such as inefficiency, uncontrolled largess, and difficulty in responding to patients’ values and preferences.

But if we’re clever and tough enough to build in “moral syndrome-friendly” interaction throughout a reformed health system, there’s no telling how much better off patients, providers, and everyone else might be. In fact, the many existing examples of syndrome-friendly interactions that support both better clinical outcomes and increased efficiency already give some cause for optimism. Thus, pay-for-performance, although hardly a panacea, honors the principle of making better clinical “widgets,” rather than just more clinical “widgets.” Pragmatic clinical trials are beginning to provide valuable information on the comparative effectiveness of new and existing interventions, strengthening further the marriage between effectiveness and efficiency. And exploration of the business case for quality suggests that better care can save “dark green dollars”—real, bankable savings, that is, not just the “light green dollars” of potential, on-paper savings.

Finally, consider patient-centered care, a concept that found little support in medicine over the centuries, but that is now emerging as a core precept in medical quality improvement. It seems right that the long-standing and widely honored commercial adage “The customer is always right” is creeping into patient care. Who would have guessed?

Frank Davidoff, MD, MACP, is editor emeritus of Annals of Internal Medicine, and executive editor of the Institute for Healthcare Improvement.

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

This essay appears in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

To deem itself civilized, a society must protect the personal integrity of its citizens. Without such protection, the integrity of the society itself unravels as more and more effort goes into protecting individuals against the chicanery of their fellow citizens. Perhaps this is why Plato called integrity “the goodness of the ordinary citizen.”

If integrity is the characteristic value for the ordinary citizen, then it’s even more important for those whose social roles are defined primarily in terms of personal trust—doctors, lawyers, ministers, and teachers. Ordinary citizens cannot be healed—or provided with advocacy, spiritual counsel, or learning—without trust in these helping professions. (Unfortunately, history recounts how some physicians in every age have failed in the trustworthiness integral to medicine.) When such professions lack integrity, those who need their services will seek to protect themselves by assuring greater individual or public control over their relationships with 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 unprecedented. The result is that the center of gravity for individual decisions has shifted sharply away from the physician to the patient. That power shift has been reinforced in law (witness the burgeoning of malpractice lawsuits and insurance) and public policy as well. However, one may rightly ask: Is the good of the patient better served when he takes charge and directs his own care, or does the erosion of trust in the physician’s integrity put the patient in danger of being morally abandoned by the physician?

I contend that autonomy gives patients the moral right to reject care and protects their human dignity, but that patient autonomy need not interfere with the integrity of the physician—unless that right is expanded in such a way that patients can demand and even direct the details of clinical care. But if autonomy is understood as a right to demand care, it not only violates the integrity of the physician, it also endangers the care of the patient. For the benefit of both patient and doctor, patient autonomy must be understood in such a way that it can coexist with physician integrity.

The Nature of Integrity

Classically, 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 without hypocrisy. He will admit mistakes, be remorseful, and accept the guilt that follows wrongdoing. The person of integrity fulfills the obligations of his private and his professional life, which are consistent with each other. He or she follows his conscience reliably and predictably. This pursuit is intrinsic to the person’s identity. To violate it is to violate that person’s humanity.

In the patient-physician relationship, both parties are entitled to protection of their personal integrity. However, the values, beliefs, and norms that comprise integrity may well be very different—and present different challenges—for doctor and patient. The physician needs to contend with an increasingly pluralistic society that can create pressure to compel him or her to accommodate patients’ differing religious, cultural, or personal beliefs. Also, the special nature of the patient-physician relationship (which derives from the fact that being sick and being healed are predicaments of special vulnerability), the growth of personal freedom of choice, the systematization of patient care, and the trend toward legal resolution of moral conflicts promise to increase the demand for personal and/or public control of the physician’s clinical decisions. All these factors encourage erosion of the physician’s personal integrity.

On the patient side, the sick or injured person—in a state of distress, pain, and suffering—is compelled to seek out and depend on the physician who professes to know how to help. The sick person and his family are asked to make choices among therapies, choose when life support may be discontinued, and decide how vigorously the terminally ill patient shall be treated. Throughout all this, the patient and family must trust the physician—or more likely a team of physicians, nurses, social workers, chaplains, etc.—each offering a slightly different rendition of the choices. Often, the physician and other caregivers are of different minds, and none may know what the best choice is. This uncertainty leads to lack of trust and may prompt the patient and family to go in desperation from Internet site to Internet site, and to nontraditional healers or marginal practitioners, in search of answers and of someone they think they can trust. Because, in the end, someone must be trusted.

The Empowerment of Autonomy

Vulnerable patients have always worried about whether their physicians possessed the competence they claimed and could be trusted to use it wisely and well. Until recently, however, they had little power to challenge the authority and sometimes authoritarianism of their physicians. Today, we live in a time of self-assertion. Autonomy, the most quoted principle of bioethics, empowers patients to challenge physicians’ knowledge and judgment. Patients now have the moral and legal rights to be informed and to give or withhold consent. Increasingly, patients and surrogates understand autonomy as empowering them to demand the care they want. Autonomy has expanded to the point that it conflicts with the physician’s moral or professional judgments.

The effect on the physician-patient relationship has been profound and complex. On the one hand, it has made that relationship more open, more adult, more transparent, and more attentive to the patient’s values and wishes. Some of the edge has been taken off physician arrogance and self-assurance, and the patient’s dignity as a person is better respected. These benefits have, however, been accompanied by trends that are dangerous to the patient and unjust to the integrity of physicians. For one thing, many physicians feel they are required to satisfy patient or family demands or be guilty of “paternalism”—the original moral sin of modern bioethics.

To avoid paternalism, some physicians and ethicists argue that physicians should be morally neutral.  Without sanctioning obvious harm, they should yield to patients who choose a less effective treatment, or a treatment of no proven use, or even one that violates the physician’s beliefs about what is right and good. Furthermore, some physicians believe that in the name of patient autonomy they must protect all confidences even when others may be harmed— for example, not reporting the incapacitated driver who is a public danger, or not revealing HIV infection to sexual partners. Others may take it as an act of beneficence to exaggerate the severity of disease or disability to increase the patient’s insurance coverage.

More subtle—but perhaps more important—is the physician’s growing reluctance to urge the course that he or she believes is preferable for this patient. Despite protestations that they know what is best for themselves, patients do make wrong choices. For the physician to suggest otherwise is to fail to respect the trust he has promised. Refusing to “bias” the patient’s choice by revealing one’s own choices—and perhaps persuading the patient to change his mind is not a true violation of autonomy. Rather, not to do so violates the principles of beneficence and trust. Beneficence does not equal “paternalism,” which relies on deception, treating the patient as a child, or coercing a choice and is itself maleficent. To cooperate in a wrong choice is complicity with what is wrong, and leaving the patient to decide difficult issues about which the physician himself may be uncertain is complicity in harm. Rather, what the patient needs is a physician who protects the moral right of patients to reject any or all treatment after the options have been frankly disclosed, and who will not use deception or ill-placed emphases to change the patient’s mind.

Overriding Physician Integrity

The desire for autonomy and unhindered freedom of choice has led to law and policy that override the physician’s objections to certain procedures, including abortion, assisted suicide, euthanasia, some methods of assisted reproduction, and embryonic stem cell research and therapy. This is not the place to argue the ethical issues of these practices. However, refusing to participate in them is essential to the moral and professional integrity of many physicians. Manipulating law and policy to make providing them mandatory by threatening loss of license or specialty certification is an assault on the very person of the objecting physician.

The trajectory of efforts to compel health professionals to provide care they find objectionable is toward relaxation or abolition of conscientious objection privileges. At this writing, there are organized attempts in the courts to block a new federal regulation that protects health workers who refuse to provide objectionable care. The ultimate goal seems to be to eliminate legal protections of conscientious objection entirely.

Policy Implications

As we approach another round of health care reform, the medical profession and the public must together find the balance that preserves both patient autonomy and physician integrity, for the benefit of both patients and physicians. Given how essential trust is in medical and health care encounters, we cannot trust physicians who shun responsibility, and we do not want patients abandoned in the midst of critical health and medical care decisions. For a morally viable relationship in a democratic society, both autonomy and integrity must be sacrosanct.

Edmund D. Pellegrino, MD, MACP, is professor emeritus of medicine and medical ethics at the Center for Clinical Bioethics at Georgetown University Medical Center. He also serves as chairman of the President’s Council on Bioethics.