Click here for a full text transcript of the conversation.

Host Ira Flatow said in his introduction:

“Lost in the fray [of acronyms and actuarial tables] is the whole reason to have the health care debate in the first place…we’re going to try to reel it back in to talk about our values. What role do they play in shaping health care policy?”

Flatow noted that in its recent collection of essays, Connecting American Values with Health Reform, “The Hastings Center has tried to bring values back into the discussion.”

Len Nichols, health policy director at the New America Foundation, also participated in the show. Nichols, a health economist who wrote an essay on stewardship for the Hastings Center collection, said that passage of the final health care reform legislation is contingent on leadership that promotes shared values. “It is sometimes true is that those values seem to differ among political antagonists….but when you probe deeply and get in a dialogue you find out the values are actually shared,” Nichols said. “I believe most people share them and therefore we will end up with a bill that moves our country forward.”

As a society, we have a moral obligation to provide access to medical care for all of our citizens. When we frame healthcare as a “right,” we shift responsibility from society to the individual. It is up to him to demand his due. At that point, the word “entitlement” comes to mind, along with the conservative image (so artfully drawn by President Reagan), of an aggrieved, resentful mob of freeloaders dunning the rest of us for having the simple good luck of being relatively healthy and relatively wealthy.

“We didn’t make them poor or sick,” some libertarians say. “Why should they have the “right” to demand so much from us?” And just how much care are they entitled to? Should they get the same care that wealthier Americans expect? Wouldn’t it be sufficient to give them care that is “good enough”?

Put simply, the language of individual “rights” doesn’t seem the best way to build solidarity. And I am convinced that social solidarity is key to improving public health.

A friend who lived in France for many years once explained to me: “Healthcare is so good in France because the French believe that nothing is too good for a fellow Frenchmen.” Unfortunately, in this country, many of us do not feel that way about each other.

But I am not willing to accept the notion that Americans are “different,” so incapable of such fellow-feeling. We are, after all, in this together. As humans we are vulnerable to disease and accident. As John F. Kennedy once put it, simply by having children we give “hostages to Fate.” This is what we have in common, our common humanity. This is why the citizens of developed nations willingly pool their resources to protect each other against the hazards of fate.

If healthcare is, in any sense, a “right,” I would argue that it is what the Declaration of Independence named an “inalienable right’” conferred on us, not by government, but by “Our Creator.” Inalienable rights are natural rights something we deserve simply by virtue of being human, so that we can be free to pursue life, liberty and happiness. These are affirmative right which empowers us to become part of society. Without our health, we cannot participate as members of a political community.

An “inalienable right” is very different from a constitutional right (to free speech, for example ) which gives the individual the right to be free from interference by government or their neighbors—to be protected against unreasonable searches, cruel and unusual punishment, or invasion of privacy. Those rights are designed to protect us, as individuals, from society. Universal healthcare acknowledges each of us as equal members of society.

This means that it is essential to think about healthcare collectively. Asking, “What will reform mean for me and my family?” is not the way to achieve universal care. We should ask “What will it mean for all of us?” How can we allocate resources to achieve affordable, sustainable, high quality care for everyone? No movement that urges history forward has ever been built on narrow self-interest.

To some, the idea of “thinking collectively” might sound un-American. But if the rights of the individual are enshrined in our value system, so is the idea that all men are created equal. And liberty and equality go hand in hand. If we want a stable society, we must have equality with regard to the necessities of life. Without stability, my rights as an individual are in jeopardy. As the 1948 United Nations Universal Declaration of Human Rights puts it: “the recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world.”

Thinking collectively also means understanding that the resources that we, as a society, have to spend on health care are finite. As a nation, we now spend well over $2 trillion on medical care and as costs continue to levitate healthcare is becoming unaffordable for many. If we want high quality care for all, we must husband our resources.

We know that today, our health care system is bloated with waste in the form of unnecessary tests, unproven treatments, and over-priced , cutting edge drugs and devices that, too often, are no better than the older treatments that they are trying to replace. More than two decades of research done at Dartmouth University (www.dartmouthatlas.org) tells us this. Moreover, this is hazardous waste. Every treatment carries some risk of side effects. If it is unnecessary, the patient is, by definition, exposed to risk without benefit.

The waste must be excised with a scalpel, not an axe. Individuals can make a difference. Both physicians and patients should think twice before ordering — or asking for – yet another MRI, a drug touted on TV, or angioplasty as a “quick fix” for chronic stable angina.

When a doctor recommends that you begin taking a sixth pill, a patient might ask: “Are you saying I absolutely should take this medication—or that it might be a good idea? I’m already taking five different drugs, and I’m a little concerned about becoming a walking pharmacy.” Your physician may well respond by saying “yes,” you do need this sixth pill. But the question could open up a conversation about whether you need the other five.

Similarly, before recommending routine PSA testing for prostate cancer, doctors should consider the advice of the American Cancer Society and discuss risks as well as the possible benefits of the test, giving patients an opportunity to make a informed choice.

All of us are responsible for trying to rein in needless spending, Washington can pass legislation, but change will happen on the ground if doctors step back and take a long look at their own ordering patterns.

This is what physicians and hospital leaders from Cedar Rapids, Iowa did when they decided to investigate the overuse of CAT scans in their community.

When they examined the data, they found that in just one year 52,000 scans were done in a community of 300,000 people. A large portion of them were almost certainly unnecessary, not to mention possibly harmful, as CAT scans have about 1,000 times as much radiation exposure as a chest X-ray. “I was embarrassed for us,” Jim Levett, a cardiac surgeon and the head of a large physician group in Cedar Rapids acknowledged. It’s just not likely that 1/6 of the population needed a CAT scan in a given year. Just by counting, these physicians became aware of the excess, and began cutting back.

The plain truth is that if we want to live in a society where everyone has access to care—and most of us do—then all of us must learn to share finite resources. This doesn’t mean that we must ration needed care. The over $2 trillion that we, as a nation, lay out for healthcare is enough to provide excellent care for all. But we must spend those dollars wisely.

Values come from the gut, not the mind, and the gut is not a sophisticated thinker about the nuances of alternative policy options.

—Jim Sabin, MD Essay: Responsibility

I’m going to do something “radical” here in the spirit of Dr. Sabin’s opening quote – and speak from my gut on the topic of responsibility.

In my opinion, it’s human nature to shirk responsibility, and our current society is a great facilitator of that natural urge. The more wealthy and technologically comfortable we become, the fewer responsibilities we have (in terms of securing basic needs), and the more empowered we are to indulge our inner narcissism. Until we accept that we all have this selfish tendency, we’ll continue to point at others and engage in a blame game that keeps us all very much in the dark about what’s really going on.

How does our lack of responsibility manifest itself in healthcare? Many of us don’t care for our bodies as we know we should – smoking, drug abuse, overeating, under exercising are rampant. We blame everyone but ourselves for our lifestyle choices while 75% of our healthcare dollars are spent treating chronic disease that’s 80% preventable. In a way that’s the end of the story.

However, we are also a very wealthy nation – with the capability of offering good healthcare benefits to all. We don’t do it partly because we don’t feel responsible enough for others (every man for himself) and partly because we know that most of the costs are preventable, and that makes us angry – why should we pay for others’ irresponsibility?

We have to find a way to meet in the middle – people need to show a good faith effort in improving their lifestyle choices, and be incentivized to do so. The wealthy should pitch in more to help with the 20% of medical costs that are unavoidable. We should continue to look for ways to make treatments more targeted and efficient, to reduce waste in the system (including defensive medicine – which requires tort reform), and to facilitate healthy lifestyle choices at all levels of society. We don’t need a new and expensive government-run healthcare system to achieve this – the power to turn this around lies within each of us. But we won’t be inspired to take on that challenge if our unhealthy choices continue to have no apparent consequences for us.

If we dislike the “evil health insurance and pharmaceutical companies” then there’s one good way to keep them out of our lives – don’t need them! It’s like reducing our dependency on foreign oil – natural gas, wind energy, and electric cars can all contribute to decreasing our utilization of oil. So too can walking, healthy eating, and physical labor reduce our dependency on drugs and health insurance.

All I can say is, there needs to be a national “come to Jesus” moment. We need to look at how we’ve all failed to be responsible (whether we didn’t care for our bodies, or didn’t help those in need as much as we could have, or both) and make a national commitment to change. Instead of shouting at one another in town halls, we should be marching around the country encouraging each other to get fit. It will take a long term commitment, sustained effort, and determination. But isn’t that the ultimate American spirit? We need to rally ourselves to our own cause – bring on the community organizers who can inspire locals to reduce their calorie intake and increase their walking/exercise quotient. If we don’t want healthcare to be rationed, then there’s only one way around it: take up the banner of personal responsibility and keep ourselves as fit as possible.  As President Obama says, “no excuses.”

We don’t necessarily need nuanced policy ideas, we need to go with our guts – or perhaps get rid of our guts – to fix healthcare.

“Fired Up! Ready to Go! Yes we can!”

If we apply those rallying cries to slimming our waistlines and kicking our bad habits – the rest of healthcare reform might actually take care of itself.

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

We in the United States are deeply committed to “responsibility” as a core American value.  Being responsible and taking responsibility are good. Being irresponsible is bad. But “responsibility” means very different things to different people. As a result, calling for “responsibility” in U.S. public discourse is like waving a red flag at a convention of bulls — it elicits passion, rancor, and disorderly conflict.

There’s no better place to go to understand the two main ways Americans take responsibility as a guiding value than the movies, especially westerns. Take the 1953 classic, Shane, in which lit­tle Joey Starrett is torn be­tween two icons of respon­sibility—his father, Joe, the homesteader, and Shane, the mysterious gunslinger cowboy. Joe and Shane em­body the two poles of re­sponsibility in U.S. moral discourse.

Joe exemplifies respon­sibility as social solidarity—building a caring community that takes responsibili­ty for the welfare of its members. Joe is committed to farm, family, and his nascent frontier town. For home­steaders like Joe, the emblem of responsibility is barn-raising, a ceremony in which the community joins to­gether to help individuals meet a basic need.

Shane exemplifies responsibility as individual action— making your own choices, doing what has to be done, and doing it on your own. For cowboys like Shane, the emblem of responsibility is the six-gun and the self-re­liance and strength that comes from skill at knowing when and how to use one.

These contrasting images of what responsibility means—communal barn-raising versus individualistic cowboy gunslinging—lie behind the current competing health care reform propos­als. They are also the source of some of the pas­sion, rancor, and disorder­ly conflict we have seen in our ineffectual previous ef­forts at health care reform.

Our love affair with the myth of the heroic cowboy enhances the attractiveness of market-based reform proposals. But in place of the cowboy, market proposals envision a heroically em­powered “consumer.” This swaggerer is armed with con­fidence, information, and choices when striding into the health care “marketplace” to make prudent “purchases” of high-quality, low-cost health care. The consumer enforces change via purchasing power and the invisible hand of the market, not a six-gun. Some of the intuitive emotion­al appeal of reform proposals that depend on competitive market forces comes from our cultur­al ego ideal of the self-reliant cowboy, who is always prepared to put “skin into the game” of life.

We can also discern the high value we place on heroic cowboys like Shane in the language of obituaries. The dead person is extolled for hav­ing “fought a brave battle” against an illness that ultimately prevailed. An old joke speaks to the worldview be­hind all our talk about fight: In India, death is a potential step away from reincarnation and toward Nirvana. In Europe, death is an existential tragedy we all must face. In the Unit­ed States, death is optional. When I was growing up, boys were taught that only sissies give up a fight. That macho approach to life may be well suited to trench warfare, but its use­fulness as a guide for health care re­form is limited.

Good Guys and Bad Guys

Proposals that emphasize universal coverage—like the single-payer plan—are enhanced by our beloved myth of social solidarity in an Edenic, barn-raising frontier. Building on the vision of a caring community that joins forces, the single-payer plan en­visions a society that pools its re­sources to minister to the health care needs of the individual. The energy for change comes from social cooper­ation—citizens contribute funds via their taxes to allow patients and clini­cians to collaborate on behalf of health.

Like westerns, health care reform proposals envision villains as well as good guys. In Shane, the bad guys are ranchers and their hired thugs. For market proposals, the bad guys are the demanding, entitled individu­als—free-riders who expect others to satisfy their expensive tastes in health care, but who are unwilling to take responsibility by putting any of their own financial skin into the game. For single-payer proposals, the bad guys are insurers who siphon money away from health care and into corporate profits and executive pay packages.

These are wildly oversimplified cartoon images of our major health care reform proposals. But values come from the gut, not the mind, and the gut is not a sophisticated thinker about the nuances of alterna­tive policy options. In addition to the logic and facts on which competing proposals are based—and the vested interests that support and oppose the different options—our visceral re­sponses to the values they embody are a significant part of what attaches us to the policies we favor and sets us against competing options.

In 1993, during the Clinton health care reform process—and forty years after Joey mournfully called “Shane! Come back!” at the end of the film—two new icons en­tered the U.S. health care reform dia-logue—Harry and Louise. In one ad­vertisement, Harry and Louise are sit­ting 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 choose. We lose.” In another, Harry asks Louise about the insurance prac­tice of community rating. She replies disapprovingly, “Everyone pays the same rate, no matter their age, even if they smoke or whatever.” Their friend Pat reports that his health in­surance costs more than doubled with community rating—treating everyone the same was a disaster for his community. Harry is shocked— “Congress can do better than that!”

Harry and Louise put nails into the coffin of the Clinton health re­form proposal. Their power came from looking like ordinary Americans and drawing on core American val­ues. They invoked an intrusive nanny state that imposes limited choices on the population and takes away the opportunity to chart one’s indepen­dent path in life. The attack on com­munity rating raises the specter of people who refuse to take responsibil­ity for their own choices (“smoking or whatever”) or for the embarrassing fact that they’ve become old and cost­ly. Like Shane, Harry and Louise want individuals to be “free” to make their own choices and to take respon­sibility for any burdens their health care needs place on others.

Policy Implications

One reason the Massachusetts health care reform plan has at­tracted so much attention nationally is the way it addresses the deeply rooted American standoff between the proponents of individual respon­sibility (Shane) and societal responsi­bility (Joe Starrett). The architects of the Massachusetts plan like to point out that it requires everyone to take responsibility. Individuals are re­quired to purchase health insurance but are free to choose among a large number of private (“nongovern­ment”) plans. Employers are required to contribute. The state is required to pay for those too poor to buy their own insurance.

Nobody loves the Massachusetts plan—it is too awkward and complex to be lovable. Libertarians hate the individual mandate. Single-payer ad­vocates hate the failure to create a public plan that covers everyone. But it threads its way through the mine­field of competing values well enough to be acceptable to a substantial ma­jority and to evade the accusation of being “socialized medicine.” At this point, the opposition is too small and too divided to undermine public sup­port.

Much like the Massachusetts plan, the ostensibly oxymoronic political philosophy of “libertarian paternal­ism” (described recently by Richard Thaler and Cass Sunstein in their book Nudge) seeks to bridge the gap between those who make individual freedom the top value and those who put the social good into first place. Libertarian paternalists favor policies that engineer choice in ways that in­fluence people’s behavior without closing off their options. In health care, libertarian paternalists would support tobacco taxes (nudging me not to smoke but still giving me the choice) and tiered pharmacy benefits (letting me get the pricier, branded drug if I wish, but forcing me to pay more). In principle, a libertarian pa­ternalist could support the Massachu­setts mandate for individually pur­chased insurance because those who object to the mandate can pay the tax penalty alternative instead, and those who follow it can choose their insur­ance from a long list of options.

In his inauguration speech, Presi­dent Obama invoked responsibility as a major theme—“What is required of us now is a new era of responsibil­ity—a recognition, on the part of every American, that we have duties to ourselves, our nation and the world.” It sounds as if the president wants to side with both Shane and Joe Starrett. That’s a direction our forthcoming health care reform poli­cy debate should take.

Jim Sabin, MD, is a clinical professor of both ambulatory care/prevention and psychiatry at Harvard Medical School and director of the Harvard Pilgrim Health Care Ethics Program.

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

The atmosphere was tense. Representatives of the insurance industry were huddled in one corner.  The other members of the Task Force on Genetic Information and Insurance, mostly academics and consumer representatives, were bunched across the room. As chair of the task force, I was in the middle, trying to make sense of the disagreement, which was growing more intense by the minute.

Our mandate was to provide recommendations about what health insurers should and should not do with genetic information. This was the early 1990s; there wasn’t much information available about an individual’s genes, but the avalanche of genetic information was gathering strength. The first few pebbles had arrived recently, and ever larger ones, such as the tests for genes linked to breast and ovarian cancer, would appear soon. We had time—not a lot, but some—to plan for how private health insurers would deal with information about our genetic risks for diseases, from the rare and inexorable progression of Huntington’s disease to far more common ones such as Parkinson’s, diabetes, and heart disease. Health insurers were accustomed to shaping policies according to the risks people presented. If someone with cancer was like a house afire, someone with a genetic risk of cancer was a house with a smoldering pile of rags in the corner.

The standoff in that room, though, was puzzling. We asked the insurers if they believed that everyone should have access to insurance whatever their risks: Yes, they agreed, everyone should have access to insurance. So, they were in favor of universal access, right? No, they adamantly insisted, universal access would be the death of the  industry. Finally, we understood what frightened them: to insurers, universal access meant that people could sail along without any insurance coverage until the day they became ill, when they could march into the insurer’s offices and demand to be covered.

That’s not what we had in mind, we explained. Everyone should have to pay their fair share and, when they needed care, their health insurance would be there to cover the cost. We described it as universal participation.  Fine, said the insurers, we can agree with that.

Among the lessons I learned from chairing the task force (including: Don’t fly from England to San Francisco and expect to control a contentious meeting), one stands out for this collection of provocative essays: understanding what’s at stake in a public policy debate is as vital as it can be elusive.

Connecting American Values with Health Reform is our effort to identify what is at stake amidst the swirling confusion of proposals for delivery systems, financing, cost control, and other details necessary for any practical reform. These details, though, are instruments carrying with them the impedimenta of history, habit, and interests.  To see things afresh, it helps to return to foundational questions: What do we want health reform to accomplish? What values should our institutions and practices be built upon, embody, and achieve?

The language of values has another virtue: Unlike health policy mavens, most Americans are baffled by the alphabet soup of program acronyms, economic models, and the difference between cost-benefit and cost-effectiveness analyses. Heck, most of us can’t explain the difference between Medicare and Medicaid. But we all understand what values are, and we can defend our preferences among them. Which leads to another reason The Hastings Center undertook this project.

Values can be wielded like cudgels to batter your opponents. That, unfortunately, has been all too common in recent political discourse. But values worth taking seriously — including all the values addressed in this collection of essays – are far more subtle, multifaceted, and interesting ideas that can cross political boundaries. Liberty, Bruce Jennings reminds us in an echo of Isaiah Berlin’s classic formulation, includes both freedom from and freedom to — and each of those meanings of liberty deserves attention in health reform. Liberty can mean the freedom from the imposition of a particular health plan and physicians; but it also demands a health care system that does not deny a would-be entrepreneur the freedom to pursue her vision, a freedom not available to the parent of a child with diabetes, for whom health insurance would be unaffordable outside the protective umbrella of a large group policy.

We chose the authors of these essays to represent a broad spectrum of beliefs. We assigned each of them a particular value to address, but we did not tell them what to say about it, other than to display the complexity residing within each value and spell out the policy implications of taking that value seriously for American health reform.

In reading these essays, I found moments of great illumination and insight along with occasional areas of disagreement; familiar ideas displayed in new and revealing aspects; new arguments, distinctions, and concepts. I was provoked, enlightened, and occasionally surprised. I hope that other readers will have a similar experience.

Most of all, I came away convinced that values are the beating heart of health reform, that these authors have begun a marvelous conversation about those values, and that the implications for American health reform are concrete and vitally important. A handful of ideas stand out.

First, simplistic understandings of values are deceptive and harmful to private insight and public discourse. Liberty, properly understood, is not the opposite of equality; justice, not the opposite of liberty; and responsibility, both personal and social, is crucial to the full realization of liberty and justice. Efficiency, an instrumental value rather than an end in itself, is intimately related to quality, solidarity, stewardship, and justice.  Core American values, rather than existing in ineluctable tension with one another, form a sturdy, mutually reinforcing foundation for health reform.

Second, when we acknowledge, as we must, that our goal is health, we are obliged to think much more broadly than our patchwork system of health care. Healthy children, healthy adults, and healthy communities are the outcome of many factors—from decent housing and safe areas for play and exercise to good jobs and schools.  Health care, crucial for episodes of acute illness and for the care of chronic diseases, is a significant but not dominant determinant of a community’s health. As responsible stewards of community resources, we should invest our finite public funds according to where they will do the most good. At times the best investment for health may be in education, job creation, or environmental protections, not in health care.

Third, the practice of individual underwriting in health insurance—making it harder to get the sicker you are — should be given a prompt funeral and buried with a stake through its heart. A concept such as actuarial fairness — which makes good moral sense in commercial insurance where risks are voluntary and the losses measured in money — has no place in deciding who gets access to the health care they need.

Fourth, efficiency and communal responsibility are essential if we are to have an affordable, effective, and sustainable health care system. This will require, at a minimum, systematically studying and improving the quality
and effectiveness of what we do in the name of health care. It will also require restructuring incentives so that providers are rewarded for results rather than for the numbers of procedures or tests they perform. There is good evidence that such changes would also lead to a higher quality of care.

Finally, the concept the task force developed more than fifteen years ago—universal participation—may be one whose time has finally come. The core idea is simple enough: everyone should be responsible for participating in whatever way is appropriate; when anyone needs health care that is reasonably effective and not financially ruinous, the care will be there for them. I was delighted to find the concept, if not the term, endorsed so often in these essays.

Whatever combination of private and public programs we choose, it’s a good time to connect American values with American health reform.

Thomas H. Murray is the President of the Hastings Center.