Dan Bednarz, Ph.D.
Jessica Pierce, Ph.D.
Barring the unexpected, this fall Congress will leave the present healthcare system largely intact. Ostensibly this will be a triumph for the healthcare industry. But it will be a Pyrrhic victory that pushes an already teetering system further toward breakdown. Regardless of the outcome in the 2009 healthcare debate there are unnoticed ethical issues we must address if we are to have any chance at a viable medical and public health system as we enter an age of economic contraction and restructuring, ecological dilemmas, and natural resource scarcity.
Simply stated, the present healthcare system is unsustainable for two sets of (interconnected) reasons, fiscal and ecological. The fiscal side receives attention in the current debate, but most discussion underestimates the problems and proposes solutions that provide little more than temporary band-aids. It is in the main unappreciated that the nation is in socioeconomic decline—primarily in the form of massive debt and defaults on that debt, deflation of asset values, and unemployment—which threatens the present healthcare system. Our collective understanding of the ecological dimension is abysmal, especially its connection to the economy, and if grasped would lead to the abandonment of politics and business as usual in medicine and throughout society.
Not recognizing these conditions will make the reckoning thornier and more chaotic when it arrives. For instance, medicine’s decades-old trajectory of growth conflicts with these driving forces. Even in its “reformed” state, medicine will seek more research funding and the pursuit of esoteric technological developments, expensive malpractice insurance coverage, MDs choosing specialization rather than primary care, and more energy and other resource consumption to practice medicine, all of which lead to cost escalation and, most importantly, natural resource depletion and ecological decline. In American we have an additional hindrance—which most modern countries like Canada, France, Great Britain, and Israel do not have: for-profit health insurance. All this combines to make American healthcare twice as expensive as most other industrial nations. Presently, medical care represents about 16% of GDP; with the economy now shrinking and healthcare costs still rising, can this healthcare system continue to expand and also generate profits? We do not believe it can.
Furthermore, we note that the baby boomer generation is set to retire at a time when its collective wealth, as represented in pension plans and other assets like stocks and real estate, has lost billions of dollars in value. Granted, there is concern among healthcare administrators about the burden the baby boomer generation will place on medicine. However, their models of this cohort passing through the medical system forecast economic growth and do not take into account the recent losses of federal and state tax revenues and personal accumulated wealth and savings. As a consequence the healthcare system is likely to be unprepared for the ominous burden of serving the baby boomers.
The conventional reply to our stark and rather dismal portrayal is that the recession is ending and once growth gets underway healthcare cost increases can once again can be offset by economic expansion; all that’s needed is some curbs—some “bending the curve”—on cost increases and cost efficiencies here and there to right the system.
But what if growth does not restart? Perhaps this is too abstract a question, so for a concrete example, we suggest that growth—real growth, not rises in stocks due to massive Federal Reserve injections of borrowed and printed money into the financial system—is likely to be stymied by peak oil. Already, oil prices are at $70 a barrel on the possibility that the recession is bottoming and may end. To us this is prima facie evidence that if demand increases oil prices will once again soar, and then perhaps again crash, because the worldwide production of oil appears to have plateaued in 2005. All data we are aware of indicate that it is improbable crude oil production can surpass the level reached in July 2008. Therefore, prolonged growth will by interrupted by the geophysical constraint of peak oil. Recall that in July 2008 oil hit $147 a barrel and six weeks later demand crashed as economies across the world began to dramatically contract.
Further, the amount of outstanding governmental, personal, and business debt is massive and will prove difficult or impossible to service even if growth does restart. It will take years to pay down this debt principle. This in itself can inhibit a return to consumer driven growth. Coming full circle, it is now clear that much of the growth of the past several decades was facilitated by consumers borrowing on the future and going into debt.
Ecological constraints are perhaps even more serious than economic ones and are, in many cases, intimately connected to them. The ecological costs of our current healthcare system have received no attention whatsoever in the current debate about reform, yet should, by our reckoning, take front and center in the current conversation. This is an ethical as well as empirical imperative, for no truly sustainable health care system is possible that doesn’t take into account the real ecological costs of health care.
The American healthcare system is wildly unsustainable by any reasonable ecological calculation. The most obvious point of focus is energy use and climate change, since the realities of global warming have finally entered the public consciousness. But there are other important considerations as well. The healthcare industry has enormous environmental costs, both upstream (as, for example, in the extraction, manufacture, and transport of the various raw materials of healthcare) and downstream (as in the contamination of groundwater with pharmaceuticals and of air with toxic byproducts from the incineration of plastics). All of these environmental costs translate either directly or indirectly into health costs, so that the hope of maintaining a healthy population is undercut by the very systems set in place to sustain people’s health.
Ecological and economic problems are intertwined, and often solutions to one set of problems will also help offset the other. Waste is a good example. By one estimate, approximately 30% of all health care spending in the U.S. is wasteful—we throw healthcare money and resources away, just like we toss millions of tons of uneaten food into dumpsters. Drugs such as antibiotics are over-prescribed, unnecessary and duplicative tests and procedures and performed.
To address the sustainability of our health care systems, there should be more explicit attention in the reform debate to what Wendell Berry calls “solving for pattern,” which describes a way of thinking about the interrelationship of problems and solutions so that we effectively address multiple, interlaced problems in ways that minimize the creation of new problems. Continued research on which treatments are most effective—both in terms of cost and health outcomes—are an excellent example of solving for pattern. Trying to reduce the frequency of redundant, unnecessary, and expensive tests and procedures is yet another win-win approach. So, too, is becoming proactive in transforming the energy infrastructure of healthcare, so that alternative energy sources—which will likely be more sustainable both economically and environmentally—are in place sooner rather than later, when government regulation, international peer-pressure, economic collapse, or absolute scarcity force catastrophic and costly changes.
Jessica Pierce is a bioethicist. You can visit her website at www.jessicapierce.net. Dan Bednarz is a sustainable health systems consultant and co-editor of Health after Oil, http://healthafteroil.wordpress.com/.