By William M. Sage
My message for President Joe Biden and his administration is a simple one. Invite physicians to create an ethical health care system. Demand that physicians take seriously that mission and work closely with other health professions and the public, sharing their power and authority.
Physicians’ silence in the face of massive health injustice, inefficiency, and waste must be called out by leaders of the medical profession for what it is: complicity. Commitment to an ethically indefensible status quo has made much-needed reform proposals seem morally threatening, rather than representing opportunities for ethical introspection and improvement. All those who profit from the current system — a large group, given $4,000,000,000,000 of annual U.S. health care spending — use physician complacency to justify their own resistance to change.
The U.S. health care system will not change without permission from health professionals, especially America’s physicians. Permission must be built on principle, and it should take the form of re-envisioning and reaffirming medical ethics. The need to do so has been evident for over two decades, but COVID-19 has increased its urgency.
Here and Now, Not There or Coming
Nearly all recent presidents – Donald Trump being the starkest exception — have convened commissions on bioethics. Typically, these bodies focus on new technologies offering both promise and peril, particularly those that raise dystopian possibilities or provoke religious as well as moral objections. Where U.S. health is concerned, however, a futuristic approach to bioethics is — ironically — short-sighted. The ethical problem isn’t what’s new. The ethical problem is what’s now.
Physicians and those who profit off them are wont to suggest that any substantial change to where power sits in U.S. health care will endanger each of us and our parents, children, and partners. However, continuing to do what the existing health care system has been designed to reward isn’t always right and is seldom enough.
In his prizewinning history of American medicine, Paul Starr documented American medicine’s astonishing success from early in the 20th century to the present day at asserting physician privileges and fending off successive threats of either government or corporate control. These cycles of medical professional self-protection were typically justified on ethical grounds, specifically physicians’ devotion to their patients. Physicians who fought managed care in the 1990s claimed that cutting costs for insured groups would compromise their absolute ethical obligations to individual patients. Echoing their earlier opposition to the failed Clinton administration reform, many physicians resisted “Obamacare” on the grounds that a national system of coverage would lead to reductions in quality of care or rationing of lifesaving services.
But a health care system that fetishizes the relationship between one physician and one patient ignores the degree to which effective 21st-century medical care departs from such nostalgic imagery and the fact that many communities lack meaningful therapeutic access and therefore receive no or paltry benefits from the status quo.
In recent decades, moreover, solid research has revealed the severe shortcomings of what American politicians used to describe routinely as “the best health care system in the world,” but now strain to praise. Medical errors are common and deadly, often because we focus unduly on individual physicians while neglecting the systems in which they practice. A “quality chasm” remains between the goals and the reality of health system performance. Overall, the U.S. provides worse care at higher cost than many other countries, squandering over a trillion dollars annually that could be productively spent on education, housing, and other social and personal benefits.
In part because we medicalize so many social problems, we fail to notice profound racial, ethnic, and economic disparities in health needs and responses — inequities that are more honestly labelled injustices. Our bloated health care system is beset by Injustice-in-passing (implicit bias and microaggression) and injustice-by-design (structural racism). Although the scientific objectivity with which we tend to approach policy analysis may obscure it, there is even injustice-on-purpose in U.S. health care. In the aggregate, these moral failures demand an immediate ethical response.
In This Together
The Biden administration has declared its commitment to rebuilding the nation’s crumbling physical infrastructure, replacing its predecessor’s mindless mantras with something socially and economically transformative. A similarly collective effort should undergird the nation’s health and health care, with direct public investment in workforce and in physical and digital infrastructure achieved through broad political mobilization and inspired by both efficiency and justice.
Obamacare largely failed that test because of its ruthless pragmatism and its fruitless quest for bipartisanship. Its perpetuation of a “managed competition” approach at the tail end of a major national recession deftly threaded a political needle — coopting powerful interest groups, avoiding politically untenable budgetary commitments, and appeasing anti-rationing ideologues and opportunists. But the Affordable Care Act neither articulated nor supported a principled vision for health that could be incorporated into our national identity. The closest the ACA came to solidarity was consumerism, defining its goals not as a national system of health and health care but as a boon to families shopping voluntarily for medical coverage and services.
Solidarity around health is neither “socialized medicine” nor a commercial scam. From risk of harm to prevention of spread to ICU access to vaccination, the COVID-19 pandemic shows us that one cannot defend the ethics of the individual without defining the ethics of the group. Making the country healthier and less vulnerable to future threats is a communitarian project, linked inextricably to recognizing and redressing the injustices that impose risks on and withhold benefits from the poor and marginalized. For this reason, Dr. Don Berwick and other physician leaders have called on the medical profession to expand its advocacy beyond medical care to encompass other matters that compound health injustice, such as mass incarceration and climate change.
Principled Pragmatism Only
For the Biden presidency to be transformational, it must keep progressive principles at the forefront. It will get things done by being strategic in priority-setting, procedure, and messaging — not by retreating to an incrementalism that discards principle out of misperceived necessity.
It does not help to overly intellectualize injustice by speaking only the language of science and evidence and process. Where moral outrage is justified, we need to display it. Similarly, appealing to self-interest is no substitute for appealing to principle. In health reform, the “business case” for improvement is a semantic repeat offender — much overused and rarely effective. With trillions of dollars flowing so freely, it is hardly a surprise that the health care sector finds it easier to keep making money the established way than to confront deep challenges offering, at best, speculative savings (as the suspension of the vaunted Haven joint venture seems to confirm).
COVID-19, by now, should have convinced us that our health care system is not the system we thought we had. The problems are simple to state, if hard to solve. Inadequate public health investment. Critical infrastructure funded mainly by revenue from elective procedures. Disparities that increase vulnerability in both exposure and prognosis. Legal authorities straining for rationality in making care accessible and responsive.
Change will happen only when the medical profession clearly proclaims, as Dr. Jerome Kassirer observed over 20 years ago, that “[a] system in which there is no equity is, in fact, already unethical.” Mr. Biden, please appoint a Commission to craft that statement and lead us forward.