Polarization and the healthcare delivery crisis

I feel deep concern about how, with issues of every sort, people today are dividing almost immediately into polar camps. I wrote my most recent book, Perspective and Guidance for a Time of Deep Discord in response. The health care delivery crisis sheds particular light on a key theme that manifests with issues of every sort, the critical importance of a new, more mature relationship to limits.

A basic observation provides guidance when issues become polarized: In times past, when we encountered polarized positions and partisan advocacy, our task was obvious and unquestioned. We assumed that there were only two options and that our job was to figure out which one was right and fight for it. As we look to the future, polarization has very different implications. We recognize that what we are seeing is left and right hands of a larger systemic picture. And the fact of polarization alerts us to the fact that neither side has yet to ask the hard questions that ultimately need to be addressed.

I first wrote about the health care delivery debate many decades ago, but I didn’t then expect that it would produce the extreme polarization we witness today. Indeed, I assumed that most people would find the topic rather boring. While radical new treatments understandably grab headlines, working out the details of health care delivery would seem more the province of hospital administrators and economic bean counters.

Asking the Hard Question
Health care delivery makes a particularly good example of just how demanding the important new questions can be. The question that provides the needed starting point for addressing the health care delivery crisis is straightforward: How do we make good policy in the face of real economic limits? But where it takes us could not be more fundamentally challenging, even transforming.

Historically, our task on confronting limits has been to defeat (or transcend) them. The health care delivery debate combines two concerns—access to care and cost containment—that when put together present us with limits that cannot be escaped. Most immediately they confront us with the reality of economic limits. And ultimately, they confront us with an even more fundamental kind of limit.

We should note that the need to address economic limits confronts the thinking of both the right and the left. As commonly articulated, the health care delivery debate pits free-market approaches against more centralized, government-directed strategies. People assume that choosing one economic approach or the other will provide a solution. In fact, we could make most any kind of approach work. But none of them can work unless we start by first acknowledging the fact of economic limits and their implications.

Health care expenditures today are spiraling uncontrollably—for everyone, whatever kind of system they employ—and there is no natural end in sight. Advocates on each side tend to pin the problem on inefficiencies and excesses. They assume that if we just get the incentives right and set curbs against unreasonable profit-taking, all will be well. But while inefficiencies and excesses play some role in today’s health care crisis, the most important factor is more basic. Spiraling costs are primarily a product of modern medicine’s great success. Early innovations—like sterilization and penicillin—were relatively cheap. More recent advances—sophisticated diagnostic procedures, exotic new medications, transplant surgeries, and more—are increasingly expensive and promise only to get more so.

Confronting Real Limits
We face a stark reality. Unless we are willing to spend an ever-expanding percentage of national resources on health care, we have no choice but to restrict health care spending. This circumstance puts before us a whole new order of ethical challenges. We’ve always rationed care, at least in the sense of withholding care from those who were not able to pay for it. But what is being required today is different. If we are to stop spiraling costs, eventually we must consciously limit health care, and not just care that is of questionable value, but care that is of real benefit.

An exercise I’ve done with groups highlights the unsettling reality of what is being asked of us. I start by handing participants a list of patient profiles—including both information about patients’ lives and information about their illnesses—along with a budget. I then send the group off to a room for two hours with instructions to decide how the money should be spent. The choices that the exercise requires of participants can be so emotionally and morally wrenching that people refuse to make them. But the exercise is not an abstraction. It presents the task we inescapably face if we are to effectively address health care limits.

An Even More Ultimate Limit
We reasonably ask just what makes the task of confronting economic limits so much more demanding than people tend to assume? The need to make agonizing choices could be enough of an explanation. But there is more, and more of major consequence. In the end, effectively confronting health care limits demands a new relationship to the most taboo of limits-related topics: our human mortality. Medicine has always been about life-and-death decisions. But limiting care in the sense I’m suggesting involves consciously withholding care that might at least delay death’s arrival. Add this recognition, and we get the needed even larger question: “What would it mean to approach health care in a way that acknowledges the importance of a new maturity in our relationship with death?”

It is important to appreciate how fundamentally this further question is new—and significant. Death represents life’s ultimate limit to what we can know and control. Always before in our history, cultural belief has served to keep death’s full significance at arm’s length. Increasingly, we are having to confront that this kind of distancing has stopped being an option. Effectively, confronting health care limits could make addressing other death-related issues such as abortion, assisted suicide, or capital punishment seem like child’s play. Psychology Today