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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. Read the rest of this entry »
Congressman John Conyers recently quipped that most healthcare reform proposals circulating in Washington are a “cacophony of crap” that evade acknowledging medical care as a human right. With Canada across the Detroit River from his impoverished congressional district he knows firsthand how the Canadian health system bests its American counterpart. It’s cheaper by half; covers everyone; citizens don’t worry about bankruptcy –they merely get treatment as needed; and the politician who brought it into existence four decades ago, Tommy Douglas, was named the most important Canadian of all time (Wayne Gretzky finished second).
Ironically, Conyers’ National Health Insurance Act (HR 676) as currently envisioned, shares a premise with those he mocks. All sides of the reform debate presuppose a return to economic growth. It follows that none confronts the possibility that our massive debt and economic woes are not temporary but the beginning of an epochal transition to a reduced level of social complexity and economic activity, which translates into a lower standard of material living that cannot support the present structure of medicine.
Indeed, most of the reformers who claim healthcare is a human right see discussions about fiscal limits as a stealth way to kill reform. And those willing only to tinker with the financing of system assume a return to economic growth will allow healthcare to continue more or less as is. With its cost at about $2 trillion in 2008 and projected to climb to $4 trillion by 2015, attempting to maintain the current system will result in, in my view, one of two unacceptable outcomes: 1) healthcare only for the wealthy or 2) a crash of the system. There is a third way still possible, and it builds on Conyers’ plan with an acknowledgement that our present “Ferrari-Jalopy” (a nod to Congressman Roscoe Bartlett for this metaphor) health system is no longer viable. We should build a Honda Civic health system for all; it’s the best realistic chance we have.
From this vantage point, the ongoing healthcare debate in Washington is anachronistic. A future oriented analysis has to include two driving forces: first, the long-term consequences of the fiscal/economic crisis and, second, the arrival of geological peak oil, which is a symptom of the Bottleneck of ecological conditions (climate change, fresh water scarcity, population pressures, dying oceans, etc.) humanity must pass through.
Most Americans do not yet appreciate how dire our debt problems have become, in part because the mainstream media avoid the issue or characterize it as a bunch of addled and angry “teabaggers.” Still, people intuitively understand that massive debt is destabilizing, although many in the center and on the left confuse our current situation with a need for deficit-financed growth. It’s one thing for a government to borrow and spend to generate new taxes, useful infrastructure and encourage new economic activity. This can –and there is argument about this- create wealth and allow the debt to be paid off. It’s quite another to “borrow” from the Social Security Trust Fund and have the Federal Reserve in essence print money to fund further deficits, especially when it goes to financial institutions that–in my view- do not create wealth but cannibalize it.
What is omitted from this economic stimulus line of reasoning is 1) you can’t cure a debt problem by taking on more and more debt and, 2) no consideration is given to the availability of natural resources, in this case the peak of light sweet crude oil extraction makes this “stimulus” strategy not just ineffective but counter-indicated. I believe we are attempting to prime (stimulate) a well that’s going dry with borrowed water (money).
Let me digress to explain the consequences of a peak in worldwide oil extraction. Peak oil “direct” argues that the out of control financial “debt machine” was toppled because as oil production hit a plateau in May 2005 this imposed a limitation that eventually inhibited growth and wealth creation. This plateau triggered the subprime meltdown, $147.00 per barrel oil, and, overall, the exposure of enormous “systemic” debt that was no longer serviceable because real growth was constrained. Peak oil “indirect” holds that whatever caused the fiscal/economic meltdown of 2007-2008 the fact of geological peak oil –now almost confirmed- interdicts any return to the old pattern of economic growth. Either way, this makes peak oil pretty important to the socioeconomic panorama, including one of our most expensive institutions, healthcare. As we see, oil is now around $70.00 during the largest economic contraction since the Great Depression on the mere expectation that a recovery might begin.
I suggest, therefore, that healthcare reform be discussed in terms of fiscal and ecological realities, not shibboleths like this recently proffered by David Brooks. “There is the liberal way in which the government takes over … and decides who gets what. And then there is the conservative way, in which cost-conscious consumers make choices in the context of a competitive marketplace.”
But who in the healthcare reform debate makes this big picture connection between debt, oil and healthcare reform? The closest discussion I’ve heard is when Bill Moyers told David Himmelstein, of Physicians for a National Health Program, a few weeks ago, “I don’t want … you to get out of here without wrestling with this very fundamental question. We’re going to have to set limits, are we not?” (Aside: As a regular viewer of his PBS show, I note that Moyers has not forthrightly addressed ecological constraints on economic growth; so this elliptical question will have to do. Moyers has, to his credit, had Kevin Phillips on his show to elucidate our fiscal plight –and Phillips acknowledges the potential of peak oil and other Bottleneck conditions to “change the game”).
Ten years from now, with my colleague’s inventiveness in figuring out expensive new things to do [referring to medicine’s fascination with expensive and esoteric technology] we’re going to have to come to grips with that. But right now, we could reform this health care system. Do everything that’s helpful for every American for what we’re now spending.
Himmelstein presumes homeostasis when in fact our socioeconomic foundation is rupturing. Since he’s worked tirelessly on universal healthcare and practiced and taught medicine for many years I’m virtually certain he is correct in the sense that there’s a lot of fat to trim (I have countless anecdotes from doctors and nurses about excesses and waste). But this does not obviate our dire fiscal/economic state and the arrival of peak oil, the driving forces now unfolding and shrinking his ten-year time line.
Granted, the “public option” being debated in Congress –if defined properly- might bring temporary financial and psychological relief to millions of beleaguered and desperate citizens; but even this short-term possibility is unsustainable.
This brings up the issue of logical incrementalism, or the “science of muddling through.” Many healthcare analysts, like Himmelstein, assume societal homeostasis and find it easy to conclude that we are muddling our way to universal coverage. From this perspective the public option appears a significant incremental step. Given debt and peak oil, I think the time for incrementalism is past. As I write, California and several other states have budgets severely out of balance. They are facing devil’s choices that only a few years ago –when Alan Greenspan was “The Maestro” of the economy and President Bush was marketing an “Ownership Society” featuring private investment accounts for Social Security contributions- would have seemed incomprehensible. But here we are experiencing the limits to growth.
Imagine the American healthcare industry as the proverbial proud oak tree that refuses to bend during a windstorm. For decades the industry has been deft at fending off resolution of the Three Cs, cost, coverage and quality of care. Predictably, this political success has nurtured a lack of resilience, by which I mean the ability of an organization to absorb exogenous shocks or disturbances and return to its original state. Read the rest of this entry »
Dr. Jessica Pierce is a writer and bioethicist. She has published a number of books, including Wild Justice: The Moral Lives of Animals, Contemporary Bioethics: A Reader with Cases (forthcoming in October, 2009) Morality Play: Case Studies in Ethics and The Ethics of Environmentally Responsible Health Care. Dr. Pierce is Associate Faculty at the University of Colorado Health Sciences Center, Center for Bioethics and Humanities. She lives in Longmont, Colorado. Her website is http://www.jessicapierce.net.
The first sentence of The Ethics of Environmentally Responsible Health Care reads, “The foundation of human health rests on healthy, stable ecosystems.” One rarely encounters this view expressed in medical literature, yet it lies at the heart of creating a sustainable modern healthcare system.
By far the majority of analyses of the American healthcare focus narrowly on reform –slight to dramatic- through rebalancing the (allegedly) three core issues of the 1) cost, 2) coverage and 3) quality of care. Pierce and Jameton locate medicine in the context of ecological sustainability, which correctly subsumes –not negates- these three issues.
As is often the case when great social change is occurring, few scholars see it coming and also offer a cogent outline of the ethical challenges posed by such momentous upheavals. Pierce and Jameton’s is one of those books.
For example, typically “medical ethics” is devoted to issues stemming from the (allegedly) sacrosanct value of what’s best for the patient. Questions about humanity’s organic connection to and responsibility to the natural environment are not asked or are given short shrift. These authors show how the earth is not a passive, inert and inexhaustible repository of goodies for medicine to dip into at will at no cost or consequence.
This book articulates an alternative discourse integral to the viability of healthcare in the 21st century, as its chapter titles evidence:
1) The Challenge of Environmental Responsibility; 2) Linking Health and Environmental Change; 3) Population and Consumption; 4) Environmental Aspects of Healthcare; 5) The Green Health Center; 6) At the Bedside; 7) Global Bioethics and Justice; and 8) New Ways of Thinking About Bioethics.
Click here to listen to Jessica’s discussion with Dan Bednarz
Recently I interviewed Gail Tverberg, “Gail the Actuary,” a co-editor of The Oil Drum, who is an invaluable source of analysis and articulation of how peak oil is manifesting itself in the world economy and its financial institutions. We began with a macroeconomic perspective and then considered then consequences for healthcare. Read the rest of this entry »
Paul Hochfeld, MD
“Health, Money and Fear” is a 48 minute video, produced by an ER Doctor who has channeled almost three decades of being frustrated with the perverse incentives of our health care (non)system. It addresses three questions about the present healthcare system:
* Why does it cost so much? Technology, the fear of liability, the dwindling supply of primary care providers, the mass marketing of prescription drugs, chaos in medical records, our unrealistic expectations (especially at the end of life), the pressure for profits that come from all directions and all the medical insurance companies that add greatly to cost and little to health.
* What does it say about us? A lot!
* What can we do about it? Plenty, but if we focus more on access than the drivers of cost, we are going to be accelerating to the cliff.
We spend twice as much per capita as our competitors internationally. Our government already foots 60% of the bill. Many other nations have universal coverage. We don’t. By any measure of health, we get worse outcomes and our population is less happy with our system. How can we be this dumb?
“Health, Money and Fear” includes interviews with, among others, Dr. Arnold Relman, Dr. Marcia Angell (both former Editor-in-Chief NEJM), Dr. Stephanie Woolhandler (Co-founder of Physicians for a National Health Program), Dr. John Kitzhaber (fellow ER Doctor/former Governor of Oregon), Paul Ginsberg (Director of the Center for Studying Health System Change), and Dan Callahan (a pioneer in the field of Medical Ethics).
The intended audience is the well educated voter, because, at its root, health care reform is less about health care than the political process in which special interests put pressure on our elected officials to the sustain status quo to the detriment of the rest of us. For more information and/or to view a trailer or the film, in chapters: www.ourailinghealthcare.com
For a review by Dan Callahan: <http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=1526>
For more information, a trailer, or to view the film, in chapters: <http://www.ourailinghealthcare.com/>
DVD’s are available for a voluntary donation (or not) by contacting the producer, Paul Hochfeld, MD through the website or at email@example.com.
by Dan Bednarz
You don’t see something until you have the right metaphor to let you perceive it.
Anyone wishing for a more humane and happier future should strive to spread ecological literacy.
William R. Catton Jr.
On October 14th President Bush informed the nation that the government would invest in financial institutions allegedly too big to fail so as to “preserve the free market.” This ideological act of contortion violated a cardinal taboo of American capitalism. Healthcare is too important to fail; yet as currently organized and operated it is flirting with system chaos and – like Wall Street and even insurance companies- susceptible to nationalization as a political and economic expediency.
The exogenous forces coming to bear on the medical community can be explained by fusing two metaphors. The first, Bad Money, characterizes the financial/fiscal dimension of the crisis, which includes the United States’ rise to unparalleled economic power through a once bountiful supply of oil. The second, the image of The Bottleneck,. points to the deep-seated and overlooked ecological forces underlying the crisis, the world’s declining oil supply presently is the most salient ecological limit– with climate change the flip side of the consequence of consuming fossil fuels.
Combining Bad Money and The Bottleneck may appear puzzling or nonsensical to many in healthcare who easily could ask: “What on earth do finance and economics have to do with the ecology -much less healthcare?!” The answer is twofold. First, the spreading financial crisis’s source is not an eruption of venality and corruption or a cyclical misfiring of capitalism; these are the symptoms, not the pathology. Second, a crisis such as this opens the human mind and, most important, institutions –which do most people’s thinking” for them- to alternative understandings, problem structuring, and solutions. In times of great upheaval explanations and actions which formerly appeared fringe or ridiculous can rapidly become pragmatic and commonsensical –like the government intervening in the financial sector, or changing the debate rhetoric in healthcare from “socialized medicine” to “universal coverage” as a matter of “national security.”