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3 The Hastings Center

Connecting AMERICANValues withHEALTHReform

A Publication of The Hastings Center

Editor: Mary CrowleyCopyeditor: Joyce GriffinEditorial Director: Gregory KaebnickDesigner: Nora Porter

Connecting American Values with Health Reform was made possible by generous sup-port from the Adelson Family Foundationand the Cranaleith Foundation.

About The Hastings CenterThe Hastings Center is a nonpartisan bioethics research institute dedicated since 1969 to exploring issues in medicine, public health, and science as they affect individuals, society, and the public interest.

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Printed in the United States of America

VALUES: The Beating Heart of Health Reform • Thomas H. Murray / ii

A Letter from New Jersey Governor Jon S. Corzine / iv

LIBERTY: Free and Equal • Bruce Jennings / 1

JUSTICE AND FAIRNESS: Mandating Universal Participation • Paul T. Menzel / 4

RESPONSIBILITY: Shane and Joe • Jim Sabin / 7

SOLIDARITY: Unfashionable, But Still American • William M. Sage / 10

MEDICAL PROGRESS: Unintended Consequences • Daniel Callahan / 13

PRIVACY: Rethinking Health Information Technology and Informed Consent • Lawrence O. Gostin / 15

PHYSICIAN INTEGRITY: Why It Is Inviolable • Edmund D. Pellegrino / 18

QUALITY: Where It Came From and Why It Matters • Frank Davidoff / 21

EFFICIENCY: Getting Clear on Our Goals • Marc J. Roberts / 24

HEALTH: The Value at Stake • Erika Blacksher / 27

STEWARDSHIP: What Kind of Society Do We Want? • Len M. Nichols / 30

C O N T E N T S

ii The Hastings Center

The atmosphere was tense. Representatives of theinsurance industry were huddled in one corner.The other members of the Task Force on Genet-

ic Information and Insurance, mostly academics andconsumer representatives, were bunched across theroom. As chair of the task force, I was in the middle, try-ing to make sense of the disagreement, which was grow-ing more intense by the minute.

Our mandate was to provide recommendations aboutwhat health insurers should and should not do with ge-netic information. This was the early 1990s; there wasn’tmuch information available about an individual’s genes,but the avalanche of genetic information was gatheringstrength. The first few pebbles had arrived recently, andever larger ones, such as the tests for genes linked tobreast and ovarian cancer, would appear soon. We hadtime—not a lot, but some—to plan for how privatehealth insurers would deal with information about ourgenetic risks for diseases, from the rare and inexorableprogression of Huntington’s disease to far more commonones such as Parkinson’s, diabetes, and heart disease.Health insurers were accustomed to shaping policies ac-cording to the risks people presented. If someone withcancer was like a house afire, someone with a genetic riskof cancer was a house with a smoldering pile of rags inthe corner.

The standoff in that room, though, was puzzling. Weasked the insurers if they believed that everyone shouldhave access to insurance whatever their risks: Yes, theyagreed, everyone should have access to insurance. So,they were in favor of universal access, right? No, they

adamantly insisted, universal access would be the deathof the industry. Finally, we understood what frightenedthem: to insurers, universal access meant that peoplecould sail along without any insurance coverage until theday they became ill, when they could march into the in-surer’s offices and demand to be covered.

That’s not what we had in mind, we explained. Every-one should have to pay their fair share and, when theyneeded care, their health insurance would be there tocover 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 taskforce (including: Don’t fly from England to San Francis-co and expect to control a contentious meeting), onestands out for this collection of provocative essays: un-derstanding what’s at stake in a public policy debate is asvital as it can be elusive.

Connecting American Values with Health Reform is oureffort to identify what is at stake amidst the swirling con-fusion of proposals for delivery systems, financing, costcontrol, and other details necessary for any practical re-form. These details, though, are instruments carryingwith them the impedimenta of history, habit, and inter-ests. To see things afresh, it helps to return to founda-tional questions: What do we want health reform to ac-complish? What values should our institutions and prac-tices be built upon, embody, and achieve?

The language of values has another virtue: Unlikehealth policy mavens, most Americans are baffled by thealphabet soup of program acronyms, economic models,and the difference between cost-benefit and cost-effec-tiveness analyses. Heck, most of us can’t explain the dif-ference between Medicare and Medicaid. But we all un-derstand what values are, and we can defend our prefer-

ValuesThe Beating Heart of Health Reform

THOMAS H. MURRAY

Thomas H. Murray, PhD, is president of The Hastings Center.

With liberty and justice for all.—The Pledge of Allegiance

IIIConnecting American Values with Health Reform

ences among them. Which leads to another reason TheHastings Center undertook this project.

Values can be wielded like cudgels to batter your oppo-nents. That, unfortunately, has been all too common inrecent political discourse. But values worth taking serious-ly—including all the values addressed in this collection ofessays—are far more subtle, multifaceted, and interestingideas that can cross political boundaries. Liberty, BruceJennings reminds us in an echo of Isaiah Berlin’s classicformulation, includes both freedom from and freedom to—and each of those meanings of liberty deserves attention inhealth reform. Liberty can mean the freedom from the im-position of a particular health plan and physicians; but italso demands a health care system that does not deny awould-be entrepreneur the freedom to pursue her vision, afreedom not available to the parent of a child with dia-betes, for whom health insurance would be unaffordableoutside the protective umbrella of a large group policy.

We chose the authors of these essays to represent abroad spectrum of beliefs. We assigned each of them aparticular value to address, but we did not tell them whatto say about it, other than to display the complexity resid-ing within each value and spell out the policy implicationsof taking that value seriously for American health reform.

In reading these essays, I found moments of great illumi-nation and insight along with occasional areas of disagree-ment; familiar ideas displayed in new and revealing as-pects; new arguments, distinctions, and concepts. I wasprovoked, enlightened, and occasionally surprised. I hopethat other readers will have a similar experience.

Most of all, I came away convinced that values are thebeating heart of health reform, that these authors havebegun a marvelous conversation about those values, andthat the implications for American health reform are con-crete and vitally important. A handful of ideas stand out.

First, simplistic understandings of values are deceptiveand harmful to private insight and public discourse. Lib-erty, properly understood, is not the opposite of equality;justice, not the opposite of liberty; and responsibility, bothpersonal and social, is crucial to the full realization of lib-erty and justice. Efficiency, an instrumental value ratherthan an end in itself, is intimately related to quality, soli-darity, stewardship, and justice. Core American values,rather than existing in ineluctable tension with one an-other, form a sturdy, mutually reinforcing foundation forhealth reform.

Second, when we acknowledge, as we must, that ourgoal is health, we are obliged to think much more broad-ly than our patchwork system of health care. Healthy chil-dren, healthy adults, and healthy communities are theoutcome of many factors—from decent housing and safeareas for play and exercise to good jobs and schools.Health care, crucial for episodes of acute illness and forthe care of chronic diseases, is a significant but not domi-nant determinant of a community’s health. As responsiblestewards of community resources, we should invest our fi-nite public funds according to where they will do the mostgood. At times the best investment for health may be ineducation, job creation, or environmental protections, notin health care.

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

Fourth, efficiency and communal responsibility are es-sential if we are to have an affordable, effective, and sus-

tainable health care system. This will require, at a mini-mum, systematically studying and improving the qualityand effectiveness of what we do in the name of healthcare. It will also require restructuring incentives so thatproviders are rewarded for results rather than for the num-bers of procedures or tests they perform. There is good ev-idence that such changes would also lead to a higher qual-ity of care.

Finally, the concept the task force developed more thanfifteen years ago—universal participation—may be onewhose time has finally come. The core idea is simpleenough: everyone should be responsible for participatingin whatever way is appropriate; when anyone needs healthcare that is reasonably effective and not financially ru-inous, the care will be there for them. I was delighted tofind the concept, if not the term, endorsed so often inthese essays.

Whatever combination of private and public programswe choose, it’s a good time to connect American valueswith American health reform.

Core American values, rather than existing in ineluctable tension with one

another, form a sturdy, mutually reinforcing foundation for health reform.

Universal participation may be a concept whose time has finally come.

iv The Hastings Center

I AM PLEASED to present to you The Hastings Center’s volume, Connecting American Valueswith Health Reform. The issues that are analyzed in this volume are of enormous importance toNew Jersey and to the United States, and they have and will continue to be of great importanceto me as governor of New Jersey.

Health care policy is often described as an arena of intense partisan and ideological division.But there are also important areas of consensus that reflect agreement about some basic, core val-ues. Health care reform will be most successful if it draws on these common values.

Both progressives and conservatives want to expand access to care. Everyone recognizes thatlack of access for low-income people violates our national commitment to civil rights and that itultimately threatens the viability of the mixed public-private health insurance system. In 2008,New Jersey passed a major expansion of our FamilyCare program to mandate health coverage ofchildren and to provide free or subsidized health insurance to low- and middle-income families,and this bill received massive Republican and Democratic support.

Both progressives and conservatives want to contain health care costs. Progressives recognizethat relentless cost increases will crowd out other social priorities and that low-income peoplebear the heaviest economic burden when health insurance costs compete against annual raises. Iam a proud progressive, but it is because of my core principles that I know we have to act when Isee New Jersey’s bill for health care now having grown to almost a third of the state budget. I andmy administration have worked hard to make progress on reducing health care cost growth, in-cluding significant reductions in excess hospital capacity and reforms to the insurance market.

Both progressives and conservatives want to build health care IT infrastructure and recognizethat—as with interstate highways (another area of political consensus)—without government in-tervention, health IT will not be developed. Both progressives and conservatives understand thecompelling moral and policy case for investing in prevention and not just in illness treatment.

These themes represent major common ground from which to work toward national healthreform.

The essays included in this book can help to elucidate the beliefs that we share, and where dis-agreements over principle are more intractable. But to make progress on the areas on which weagree, we will also need to overcome the sense that health reform is a zero-sum game in whichone ideology and one party can only win if the other loses. It is my hope that this volume canhelp us to recognize that getting health care right reflects American values.

Jon S. CorzineGovernorState of New Jersey

State of New JerseyOFFICE OF THE GOVERNOR

1Connecting American Values with Health Reform

America is the child of John Locke, the greatphilosopher of liberalism and natural rights. Thiscommonplace observation holds a key to under-

standing the politics of health reform in the UnitedStates. The tradition of liberalism (in the philosophicalsense of the term) is still the context of our politicalmorality, our constitutional law, and much of our publicpolicy. Liberty is the fundamental value of American pol-itics; not the only one, to be sure, but the fundamentalone nonetheless. Liberty has been central to the ethicaljustification for health reform in the past, and it will con-tinue to be in the future.

As a fundamental value in American life, liberty hasseveral interesting characteristics. It is talked about a lot;the word itself is often used, both in political and every-day speech, but even when the word is not spoken, theidea is there. Liberty is pretty much synonymous withfreedom and, in bioethics jargon, with “autonomy.” Lib-erty often goes incognito, its resonance embedded inother values or ideas that on the surface seem to be aboutsomething else. For instance, liberty resides in terms likeprivacy, choice, property, civil rights, entrepreneurialism,markets, dignity, respect, individuality. Values so ubiqui-tous are often taken for granted and not sufficiently scru-tinized. They therefore have great political power yet arevulnerable to cynical misuse and manipulation. Liberty is

no exception, and we need to think carefully and critical-ly about its history, meaning, and political implications.

Properly understood, liberty should be compatiblewith other ethical values that have often been pitted inconflict with it, such as equity. Such a conflict has beenthought to arise, for example, when allowing all individ-uals the freedom to accumulate as much as they can un-dermines the capacity of the entire society to ensure thateach individual receives a fair share. Why is this clash be-tween appropriation and redistribution seen as a clash be-tween liberty and equity? In order to set up this conflictin the first place, one must conceive of liberty as the un-bridled expression of possessive individualism. But this isnot the only or the most fruitful way to understand lib-erty. Herein lies my principal point: progress in establish-ing an ethical and political justification for health reformdepends on reconciling liberty and equity, at least in thearena of health affairs. We must break out of the ideolog-ical grid that sets liberty and equity in opposition, indeedin a zero-sum relationship such that one of these valuescancels out the other. The health reform conversation hasto be reframed at the grass roots level so that a new wayof seeing what liberty is and what it requires will growout of that conversation. One tenet of this movementshould be that equity in access to health care, reductionin group disparities in health status, and greater attentionto the social determinants of the health of populationsand individuals are all policy goals through which libertywill be enhanced, not diminished.

LibertyFree and Equal

BRUCE JENNINGS

Liberty without equality is a name of noble sound and squalid result.

—L.T. Hobhouse

Bruce Jennings, MA, is director of of the Center for Humans andNature and a senior consultant at The Hastings Center. He teach-es ethics at the Yale School of Public Health.


What Liberty Has Meant

The history and politics of healthreform is an object lesson in this

regard. In the past, appeals to thevalue of liberty have most often beenmade by opponents of governmentalinvolvement and structural change.In the street language of Americanpolitics throughout the twentiethcentury, the main threat to libertywas “socialism” (a.k.a. big govern-ment), and the key plank of the in-dictment against health reform plans,from Woodrow Wilson through BillClinton, was the specter of “socializedmedicine.” The main ally of liberty inthe same period was free marketcompetition. Health reformers strug-gled (mostly in vain, it must be said)against this interpretation of liberty.They countered with an appeal to thelanguage of rights and to the counter-vailing value of equality. (Equality’saliases are equity, fairness, social jus-tice, solidarity.)

Stepping back, we can see thathealth reform has been caught in thesame web of dichotomies and con-flicting values that have ensnaredevery other facet of progressive andwelfare state measures during the lastcentury. Some of the worst snarls inthis intricate web are: (1) individualresponsibility and choice versus socialassistance; (2) market initiative andcompetition versus governmental reg-ulation and bureaucratic red tape; (3)efficiency versus entitlement; (4) au-tonomy (rugged individualism) ver-sus elite paternalism (Big Brother, thenanny state, father knows best); andfinally, at the personal, gut level, (5)fear of losing current benefits andquality services versus guilt based ona sense of justice and concern forthose excluded from the current sys-tem, especially children and the “de-

serving” poor. I believe that we willnever be able to resolve these di-chotomies or untangle this web. In-stead, what we need to do is tochange the subject and reconceptual-ize the terms of these past dead-enddebates.

The most recent large-scale healthreform effort in the United States,during President Clinton’s first termin the early 1990s, featured each ofthese snarls. No doubt there are manyreasons why this plan was defeated inCongress, perhaps not the least ofwhich was that big business ultimate-ly decided that it could get a betterdeal to hold down health care costsfrom a private managed care ap-proach than it could from Clinton’scombination of managed competi-tion and a global health care budget.But at the level of public opinion, thedebate tended to center more aroundindividual liberty versus social equity.A mainstay of the attack on the Clin-ton plan—policy experts dismissedthis as obvious nonsense, but it had a

significant political effect—was thefear of losing personal liberty, and inparticular, fear of losing the freedomto choose one’s own doctor and tocontrol one’s own health care. Thetelevision advertising campaignagainst the Clinton plan, sponsoredby a health insurance industry tradegroup and featuring the concernedmiddle-class couple Harry andLouise, focused on the loss of libertyand the erosion of quality that theplan would bring about. These pro-fessionally produced ads used theconcept of liberty very artfully.

What is it about liberty that turnsit into an arrow in the quiver of op-ponents of health reform? Is there away to reframe it and to develop analternative way of using it? Is thereany reason to think that such a refor-mulation would have any traction inforthcoming political debate and thepolicy process? These will become in-creasingly important questions, I be-lieve, in the round of health reformdebate that is now beginning.

Unveiling the Statue of Libertyby Edward Moran

What Liberty Should Mean

The concept of liberty has two dif-ferent facets, which are usually

referred to as “negative liberty” and“positive liberty.” Negative liberty isabout being free from obstacles orconstraints: it is about having free-dom of choice—even the freedom tomake mistakes and poor choices.Having personal security and civilrights ensures negative liberty. Posi-tive liberty is about being free to haveoptions—being enabled or empow-ered to make choices or realize per-sonal goals. Having the right to free-dom of speech is a negative liberty;having access to an education thatgives you something thoughtful tosay is a positive liberty. Positive liber-ty is about having others do some-thing for or with you that gives youthe opportunity to change your lifeor achieve your goals. In a nutshell:negative liberty is about “don’t treadon me”; positive liberty is about “Ineed you to help me up.”

The libertarian interpretation ofliberty and the privatized marketmodel of health care err by focusingtoo exclusively on the negative side ofliberty. Health care is inextricablybound up with the value of liberty,not simply because it prevents illnessfrom limiting your life decisions, butalso because it enables you to useyour freedom more richly, to liveyour life in more meaningful andworthwhile ways. Health care is notsimply about preserving you from the“outside” interference of others or ofdisease; it is also about obtaining theactive assistance of others so as to en-hance the types of activities you canpursue and the kinds of relationshipsyou can have. Thus, health care is asmuch about positive liberty as it is

about negative liberty. And what istrue of health care is true as well ofhealth itself, or of health status.

The positive, relational, and en-abling side of liberty is what links itto equity. The zero-sum relationshipbetween liberty and equity is an opti-cal illusion that comes from an exclu-sive focus on negative liberty. Positiveliberty is the concept that reminds usthat the well-being of one individualis not a function of isolation but ofcontext, community, and mutual in-terdependency. Equity is about mu-tual flourishing; negative liberty isabout individual flourishing no mat-ter what the condition of others; pos-itive liberty is about the connectionbetween individual flourishing andmutual flourishing. Positive libertyreminds us that no single individual,no matter how wealthy or powerful,can really be free except in a contextof social justice and the commongood.

Policy Implications

The health reform debate of thecoming years will have a broader

focus than past reform debates. It willnot just be about acute-care healthinsurance reform and access to clini-cal, treatment-oriented medical ser-vices and technologies. Instead, it willtake up the larger structural determi-nants of health and health promo-tion. The access to acute care andhigh technology clinical services isvery important to particular individ-

uals at particular times, but such ac-cess has been shown to have little ef-fect on population health as a whole.And even at the individual level, themost important and challenging pol-icy goal is access to health, not mere-ly access to clinical medical care.Building a system that generates orpromotes health requires that peoplehave access to many specific and pos-itive aspects of their natural and so-cial environments. Achieving greaterhealth for the whole population—ahealthier nation—will require large-scale social reform and institutionaltransformation. These changes pointin the direction of a more global kindof equity and social justice.

The role of liberty will change inhealth reform debates when twothings happen. First, we must see thathealth reform involves equitable ac-cess to the social preconditions ofhealth, as well as to health care. Sec-ond, we must see that when anyonelacks such access, the liberty of all(not just of those who experience theinequity) is compromised. This, I be-lieve, is where the health policy con-versation is going in the years ahead,and as this shift occurs we will re-think the meaning and uses of thevalue of liberty in political argument.Liberty rethought can then be one ofthe touchstones for a democratic,grass roots movement for health re-form that will demand health justicein a nation of free and equalpersons.


Establishing an ethical and political justification for

health reform depends on reconciling liberty and equity.

Convictions about justice are a deep and persistentforce in health care. It seems distinctly unjust andunfair, for example, that one victim of a disease

dies or is permanently impaired and financially devastat-ed, while another with the same disease is readily curedand lives financially unscarred.

Yet convictions about what is unjust do not necessari-ly steer us quickly toward universal access to basic care.Beyond political and economic self-interest, conflicts be-tween justice and allegedly competing values like libertymay intrude. Also, there are different senses of justice it-self, varying widely across the moral and political spec-trum. Those who think it unjust that one person can beruined by an illness that leaves somebody else, who hasgreater resources, unscathed, are looking to a relativelyegalitarian sense of justice. That sense pushes toward uni-versal access and its equitable financing. Some libertarianviews of justice, on the other hand, contend that thosewho have no contractual or special relationship with theunlucky victim of disease—and have not themselves ex-acerbated her plight—have no obligation to assist her.

Despite these complications, several claims about jus-tice and fairness may be based broadly enough in U.S.moral and political culture to guide society’s debate. Acase for mandated universal coverage built on seven suchclaims is outlined below, followed by a discussion of howsuch a policy embraces the values of liberty and justice.

Why Mandated Universal Coverage Is Just and Fair

We have already collectively decided to prevent hospitalsfrom turning away the uninsured. In such a context, allow-ing insurance to remain voluntary is unfair to many of theinsured. The obvious way to alleviate this unfairness is tomandate insurance.

Since 1989, by federal law (the Emergency Treatmentand Labor Act), hospitals have been prohibited from re-fusing acute care to those who cannot afford to pay. Con-sequently, $100 billion of care is annually “cost-shifted”onto patients who can pay, almost all of whom are in-sured. This shift raises the average annual health insur-ance premium roughly $1,000 for every insured family.Some of the uninsured are working families and youngsingles; when they need emergency care and get it at littlecost, others who are economically similar but have chosento insure end up invisibly footing part of the cost. Ar-guably, those uninsured who so benefit without bearingany share of cost are unfairly free-riding. Only two ac-tions can avoid this: either repeal the rescue requirementon hospitals, or mandate insurance. Few support the for-mer, so let’s face the matter and mandate insurance.

A mandate that everyone be insured is unfair unless in-surance is affordable, but in any multipayer system, afford-ability requires both income-related subsidies and restrictionson the behavior of insurers.

Given the cost of even basic insurance, many people ofmodest means who do not qualify for Medicaid cannotreasonably afford insurance without a subsidy. In addi-


Justice and FairnessMandating Universal Participation

PAUL T. MENZEL

Nothing is to be preferred before justice.—Socrates

Paul T. Menzel, PhD, is professor of philosophy at Pacific Luther-an University and has published widely on philosophical ques-tions in health economics and health policy.

tion, insurance will not be affordablefor anyone who already has healthconditions likely to require higher-than-average annual expenditures un-less insurers are prevented from carv-ing out their favored clientele bymeans of preexisting condition exclu-sions and “risk-rated” premiums.

Unless insurance is mandatory, it isunfair to bar insurers from using preex-isting condition exclusions, waiting pe-riods, and risk-rated premiums.

Feasible access to insurance for thepeople who most need it suffersgreatly when voluntary insurance thatpermits the healthiest to go withoutcoverage gets combined with widelatitude for insurer strategies to re-cruit optimal subscribers. The effec-tive path to access, however, is notmerely to bar insurers from usingsuch strategies. To do so would ex-pose them to potentially lethal eco-nomic risk (through “adverse selec-tion”). It would also raise premiumsfor healthy young people, who inturn would be even less likely to in-sure; thus the number of uninsuredmight actually increase! People whowant to postpone insurance, thinkingits expense to be a poor bargain giventheir current good health, should notbe allowed to pick their time to getinsured. To receive benefits in timesof crisis, people need to pay in allalong.

Justice between the well and the illrequires that they share most of the fi-nancial burdens of illness, as well as in-surance.

Mandating insurance togetherwith sharply restricting insurers’ prac-tices is not only practically necessaryto achieve access. It also fundamen-tally aligns with justice between theill and the well. Some principle ofjust sharing between them emergesfrom widely held convictions aboutthe importance of assuring equalityof opportunity. One attractive ver-sion of such a principle is that the fi-nancial burdens of medical misfor-tune ought to be shared relativelyequally by well and ill alike, exceptwhen people can be reasonably ex-pected to minimize those burdens by

their own choices—by avoidingovereating that exacerbates (or evencreates) diabetes, for example. It fol-lows that the cost of insurance shouldseldom depend heavily on a person’shealth conditions.

We can’t have it all: setting hard pri-orities among different health care ser-vices (“rationing,” if you will) is not un-just or unfair to patients who wouldhave regarded such limits as wise andprudent prior to becoming ill.

Everyone has reason to worryabout the expenditures providers andpatients will run up. Once insured—and once ill—patients will want toget and providers will want to pro-vide all the care that has any prospectof net benefit, regardless of how smallthe benefit is, or how expensive itscost. Every system of insurance thusneeds to police the care it provides,restricting care at the margins of(low) benefit and (high) expense. Callthose limits “priority setting,” “prac-tice guidelines,” “rationing,” or what-ever: they are absolutely necessary to

control costs in a system of insuredcare. They are not unfair to patientsjust because the patient might havebenefited from the marginal carewithheld. If knowledgeable sub-scribers, in selecting insurance before-hand and having to pay for it withpremiums or taxes, would have de-cided that such care was not worth itshigher premium cost, then sub-scribers’ own values are the source ofthe limitations that define “wise andprudent” insurance.

Justice does not require universal ac-cess to all care, but only to “basic” care.Justice can tolerate additional, more ex-pansive tiers of health care for those whochoose to pay for it with their own ad-ditional means.

From whose perspective—the rel-atively wealthy subscriber, or the per-son of more modest means—shouldthe decision about the boundaries of

wise and prudent insurance be made?Arguably, the person of modestmeans. The first demand of justice inhealth care is for universal access tocare that has been proven effectiveand whose expense-to-benefit ratio isnot so high that it leads thoughtful,middle-class subscribers to pull itfrom the package they are willing tofund. The compelling obligations ofthose who are well to help fund carefor the sick, and of the relativelywealthy to help fund insurance forthe relatively poor, stop at this line.People can continue to argue aboutwhether health insurance should bemore insulated than this from varia-tions in affordability, but in a societycommitted to only modest measuresof income redistribution generally,collective action will be out of bal-ance if it guarantees everyone accessto care above this line. Of course,some will wish to include greater cov-erage, including unproven care ofhighly speculative benefit. So be it:they are free to buy up to it with their

own devices. Keeping the package ofbasic care relatively lean and thus af-fordable to subscribers and sustain-able for taxpayers will never be easy,and pressures from particular interestgroups will often need to be resisted.

Financing insurance through thecurrent taxable income exclusion foremployer-paid premiums is highly re-gressive and hardly just. If purchasedinsurance continues to play a major rolein health care, a less regressive, fairersubsidy for access is required.

Currently, roughly half the popu-lation is insured through employer-sponsored plans, whose premiums areexcluded from the employee’s taxableincome. This roughly 40 percent taxsubsidy (when the employer’s andemployee’s FICA and Medicare taxesare included) is distinctly regressive,benefiting those in the higher taxbrackets the most. Such a structure


Justice does not require universal access to all care,

but only to “basic” care.

for the society’s primary incentive forpurchasing insurance is hardly fair. Asecond questionable aspect is the sub-sidy’s lack of any limit on the premi-ums excluded; cost control in healthcare is thus discouraged, and generalaffordability aggravated further. Evenif health insurance remains signifi-cantly based in individual or employ-er subscription, a capped tax credit isfairer. It would also likely be more ef-fective in persuading lower-incomeemployees and low-payroll employersto insure.

How Mandated UniversalCoverage Supports Liberty

Some claim that individual libertyand responsibility conflict with

both universal access and any form ofmandatory or societal insurance.Mandating insurance may be just andfair, but it certainly appears to limitliberty, and whatever relatively uni-form level of “basic care” is used todefine universal access ridesroughshod over the often very differ-ent views individuals have aboutwhat health services merit funding.The challenge in countering such aview is to consider liberty in its fullercontext, as bound up with responsi-bility—where both are connected tojustice and fairness:

• Lack of access to basic care se-verely undermines people’s abili-ty to be responsible for them-selves and their families. Un-treated illness has this effect, andso does the financial hardship(even bankruptcy) often causedby uninsured medical expenses.

• The prevention of unfair free-riding—a driving force behindthe move to mandatory insur-ance—is itself based in the valueof individual responsibility: noone should get to ride the systemwithout contributing to its up-keep.

• The principle of just sharingbetween the well and the ill iskey to the argument for universalaccess to basic care, but it isgrounded on convictions aboutequal opportunity for humanwell-being. That focus of justiceon equal opportunity, not onequal well-being itself, inherentlyincludes liberty and responsibili-ty. The enterprise of achievingjustice is therefore not a matterof “leveling,” but of expandingand energizing.

• Even limitations on coveredservices—that curse of healthcare politics, “rationing”—mayat bottom be tied to the conceptof liberty, insofar as these limita-tions reflect our liberty as citi-zens to determine what and howmuch will be spent on healthcare, using our values.

Arguments for universal access andmandatory insurance that invoke jus-tice and fairness can thus be based infundamentally liberty-friendly values.There is broader room for moral andpolitical agreement than at first meetsthe eye.

Policy Implications

• Insurance for basic caremust—at least eventually—bemandatory and universal.

• If the system retains employeror individual premiums, theymust not be significantly higherfor people who are likely to bechronically ill than for those whoare likely to be well.

• Guaranteed, universal accessshould be to a limited scope ofcare that is of proven effective-ness and reasonable cost-effec-tiveness. Costs must be con-trolled, even if this requires set-ting priorities and excludingsome kinds of care. Peopleshould be at liberty, however, tobuy more inclusive insurance.

• Both single- and multipayersystems can be just. Any multi-payer system will have to set acommon framework for basic in-surance and sharply restrict in-surers’ efforts to recruit the mostprofitable subscribers. Financialincentives should promote faircompetition both among privateinsurers and between private andpublic insurance.

• The current tax subsidy for pri-vate insurance—the uncappedexclusion of employer sponsoredpremiums from taxable in-come—should be changed to asubsidy that is less regressive andmore effective at controllingcosts.


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 re-sult, calling for “responsibility” in U.S. public discourse islike waving a red flag at a convention of bulls—it elicitspassion, rancor, and disorderly conflict.

There’s no better place to go to understand the twomain ways Americans take responsibility as a guidingvalue than the movies, especially westerns. Take the 1953classic, Shane, in which lit-tle Joey Starrett is torn be-tween two icons of respon-sibility—his father, Joe, thehomesteader, and Shane,the mysterious gunslingercowboy. Joe and Shane em-body the two poles of re-sponsibility in U.S. moraldiscourse.

Joe exemplifies respon-sibility as social solidari-ty—building a caring community that takes responsibili-ty for the welfare of its members. Joe is committed tofarm, family, and his nascent frontier town. For home-steaders like Joe, the emblem of responsibility is barn-

raising, a ceremony in which the community joins to-gether 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, theemblem of responsibility is the six-gun and the self-re-liance and strength that comes from skill at knowingwhen and how to use one.

These contrasting images of what responsibilitymeans—communal barn-raising versus individualisticcowboy gunslinging—lie behind the current competing

health care reform propos-als. They are also thesource of some of the pas-sion, rancor, and disorder-ly conflict we have seen inour ineffectual previous ef-forts at health care reform.

Our love affair with themyth of the heroic cowboyenhances the attractivenessof market-based reformproposals. But in place of

the cowboy, market proposals envision a heroically em-powered “consumer.” This swaggerer is armed with con-fidence, information, and choices when striding into thehealth care “marketplace” to make prudent “purchases” ofhigh-quality, low-cost health care. The consumer enforceschange via purchasing power and the invisible hand ofthe market, not a six-gun. Some of the intuitive emotion-al appeal of reform proposals that depend on competitive


ResponsibilityShane and Joe

JIM SABIN

Man is condemned to be free; because once thrown into the world, he is responsible

for everything he does.—Jean-Paul Sartre

Jim Sabin, MD, is a clinical professor of both ambulatorycare/prevention and psychiatry at Harvard Medical School and di-rector of the Harvard Pilgrim Health Care Ethics Program.

Values come from the gut, not the mind.

Our visceral responses to the values that

reform proposals embody are a significant

part of what attaches us to the policies we

favor and sets us against competing options.

market forces comes from our cultur-al ego ideal of the self-reliant cowboy,who is always prepared to put “skininto the game” of life.

We can also discern the high valuewe place on heroic cowboys likeShane in the language of obituaries.The dead person is extolled for hav-ing “fought a brave battle” against anillness that ultimately prevailed. Anold joke speaks to the worldview be-hind all our talk about fight: In India,death is a potential step away fromreincarnation and toward Nirvana. InEurope, death is an existentialtragedy we all must face. In the Unit-ed States, death is optional. When Iwas growing up, boys were taughtthat only sissies give up a fight. Thatmacho approach to life may be wellsuited to trench warfare, but its use-fulness as a guide for health care re-form is limited.

Good Guys and Bad Guys

Proposals that emphasize universalcoverage—like the single-payer

plan—are enhanced by our belovedmyth of social solidarity in an Edenic,barn-raising frontier. Building on thevision of a caring community thatjoins forces, the single-payer plan en-visions a society that pools its re-sources to minister to the health careneeds of the individual. The energyfor change comes from social cooper-

ation—citizens contribute funds viatheir taxes to allow patients and clini-cians to collaborate on behalf ofhealth.

Like westerns, health care reformproposals envision villains as well asgood guys. In Shane, the bad guys areranchers and their hired thugs. Formarket proposals, the bad guys arethe demanding, entitled individu-als—free-riders who expect others tosatisfy their expensive tastes in healthcare, but who are unwilling to takeresponsibility by putting any of theirown financial skin into the game. Forsingle-payer proposals, the bad guysare insurers who siphon money awayfrom health care and into corporateprofits and executive pay packages.

These are wildly oversimplifiedcartoon images of our major healthcare reform proposals. But valuescome from the gut, not the mind,and the gut is not a sophisticatedthinker about the nuances of alterna-tive policy options. In addition to thelogic and facts on which competingproposals are based—and the vestedinterests that support and oppose thedifferent options—our visceral re-sponses to the values they embody area significant part of what attaches usto the policies we favor and sets usagainst competing options.

In 1993, during the Clintonhealth care reform process—andforty years after Joey mournfully

called “Shane! Come back!” at theend of the film—two new icons en-tered the U.S. health care reform dia-logue—Harry and Louise. In one ad-vertisement, Harry and Louise are sit-ting at their kitchen table. In thebackground an ominous voice says“the government may force us to pickfrom a few health care plans designedby government bureaucrats.” Harryand Louise agree—“Having choiceswe don’t like is no choice at all. Theychoose. We lose.” In another, Harryasks Louise about the insurance prac-tice of community rating. She repliesdisapprovingly, “Everyone pays thesame rate, no matter their age, even ifthey smoke or whatever.” Theirfriend Pat reports that his health in-surance costs more than doubledwith community rating—treatingeveryone the same was a disaster forhis community. Harry is shocked—“Congress can do better than that!”

Harry and Louise put nails intothe coffin of the Clinton health re-form proposal. Their power camefrom looking like ordinary Americansand drawing on core American val-ues. They invoked an intrusive nannystate that imposes limited choices onthe population and takes away theopportunity to chart one’s indepen-dent path in life. The attack on com-munity rating raises the specter ofpeople who refuse to take responsibil-ity for their own choices (“smokingor whatever”) or for the embarrassingfact that they’ve become old and cost-ly. Like Shane, Harry and Louisewant individuals to be “free” to maketheir own choices and to take respon-sibility for any burdens their healthcare needs place on others.


Torn between two models of responsibility. Left to right: Brandonde Wilde as Joey, Van Heflin as Joe Starrett, and Alan Ladd as Shane.

Policy Implications

One reason the Massachusettshealth care reform plan has at-

tracted so much attention nationallyis the way it addresses the deeplyrooted American standoff betweenthe proponents of individual respon-sibility (Shane) and societal responsi-bility (Joe Starrett). The architects ofthe Massachusetts plan like to pointout that it requires everyone to takeresponsibility. Individuals are re-quired to purchase health insurancebut are free to choose among a largenumber of private (“nongovern-ment”) plans. Employers are requiredto contribute. The state is required topay for those too poor to buy theirown insurance.

Nobody loves the Massachusettsplan—it is too awkward and complexto be lovable. Libertarians hate theindividual mandate. Single-payer ad-vocates hate the failure to create a

public plan that covers everyone. Butit threads its way through the mine-field of competing values well enoughto be acceptable to a substantial ma-jority and to evade the accusation ofbeing “socialized medicine.” At thispoint, the opposition is too small andtoo divided to undermine public sup-port.

Much like the Massachusetts plan,the ostensibly oxymoronic politicalphilosophy of “libertarian paternal-ism” (described recently by RichardThaler and Cass Sunstein in theirbook Nudge) seeks to bridge the gapbetween those who make individualfreedom the top value and those whoput the social good into first place.Libertarian paternalists favor policiesthat engineer choice in ways that in-fluence people’s behavior withoutclosing off their options. In healthcare, libertarian paternalists wouldsupport tobacco taxes (nudging menot to smoke but still giving me the

choice) and tiered pharmacy benefits(letting me get the pricier, brandeddrug if I wish, but forcing me to paymore). In principle, a libertarian pa-ternalist could support the Massachu-setts mandate for individually pur-chased insurance because those whoobject to the mandate can pay the taxpenalty alternative instead, and thosewho follow it can choose their insur-ance from a long list of options.

In his inauguration speech, Presi-dent Obama invoked responsibilityas a major theme—“What is requiredof us now is a new era of responsibil-ity—a recognition, on the part ofevery American, that we have dutiesto ourselves, our nation and theworld.” It sounds as if the presidentwants to side with both Shane andJoe Starrett. That’s a direction ourforthcoming health care reform poli-cy debate should take.


Illness, we are often told, is a private matter. Accord-ingly, none must interfere in the medical decisionsthat emerge from the confidential relationship be-

tween physician and patient. Yet evidence of interdepen-dence is ubiquitous in health care. One person’s maladycan harm families, workplaces, clubs, churches, andsometimes entire communities. Similarly, a suffering pa-tient must rely on many individuals, associational groups,corporate entities, and government agencies for supportand assistance. It is, therefore, unsurprising that varioussocial units claim an interest and a voice in maintaininghealth and treating disease.

However, explicit solidarity has long been out of voguein America’s value system, despite persistent lack of af-fordable medical care. Instead, the public has prized sci-entific innovation, consumer sovereignty, and personalautonomy, and has installed physicians as benevolent oli-garchs to oversee these functions. The resulting systemdelivers idiosyncratic care at enormous expense to mostAmericans, while a sizable minority often goes without.

Calls for solidarity in American health care reach re-ceptive ears mainly when spoken in fear—recently ofpandemic disease, bioterrorism, and natural disaster. Al-though crisis is a perpetual and therefore meaningless ad-jective in health policy debates, calamity seems to breedtogetherness. Foxholes tend to convert libertarians intocommunitarians as well as atheists into believers. Special

concern is provoked by novel pathogens, runaway tech-nologies, and random, large-scale events.

The economic downturn, with its emerging consensusthat something must be done to universalize the U.S.health care system, presents an unexpected opportunityto revisit health solidarity. Whether hard economic timesare sufficiently calamitous to become a unifying force re-mains to be seen. If so, we should be grateful that thestreets are littered merely with dead businesses, not withdead bodies, and that toxic assets rather than toxic agentsare responsible.

Beyond these base emotions, one can identify threesources of solidarity that reflect American society’s betternature. I shall call them mutual assistance, patriotism,and coordinated investment.

Mutual Assistance

Mutual assistance rooted in both compassion and ex-pectation of reciprocity accounts for the bulk of

U.S. health solidarity. Misfortune attributable to chanceor resulting inevitably from the passage of time—nottemptation or moral failing—typically triggers collectivesupport to prevent avoidable deaths, ameliorate suffering,and save victims’ families from impoverishment.

Sharing the financial risk of poor health can be ac-complished through processes of varying formality, rang-ing from charitable campaigns (such as donations to hos-pitals) to means-tested entitlements (Medicaid) to full-blown social insurance (Medicare Part A). These effortsopenly redistribute wealth but greatly assist recipients


SolidarityUnfashionable, But Still American

WILLIAM M. SAGE

We must all hang together or assuredly we shall all hang separately.

—Benjamin Franklin

William M. Sage, MD, JD, is vice provost for health affairs andJames R. Dougherty Chair for Faculty Excellence at the Universi-ty of Texas in Austin.

and, at least for voluntary charity, en-hance the well-being of donors.Health is a natural area for mutualaid because those contributing be-lieve that those receiving aid are seri-ously ill and thus have no higher usefor resources than medical care. Thismitigates concerns that aid might dis-courage self-help and promote wel-fare dependency. Mutual assistance isstrongest when donors can identifywith potential beneficiaries; nationswith the most generous social insur-ance programs tend to be those thatare demographically homogeneous.

Mutual assistance occurs in privatehealth insurance as well as public pro-grams. Group rates for employment-based coverage redistribute resourcesfrom healthier to sicker members ofworkplace risk pools. Americansreadily accept this mode of mutualsupport because they identify withfellow workers. It is undoubtedlymade more palatable by the selectivesubsidy awarded employee benefitplans under the federal tax code, bylack of transparency regarding themagnitude of the transfer, and by thewidely credited fiction that themoney involved is the employer’srather than the employees’.

Similarly, Americans routinelyempower health care providers tomake decisions about how to distrib-ute shared resources because they canimagine lives being saved. A seldom-noted aspect of the backlash againstmanaged care derived from percep-tions that HMOs were convertingotherwise acceptable cross-subsidiesinto corporate profits and thereby de-priving the health care system ofneeded funds. Historically, physicianscharged higher fees to wealthy pa-tients and offered free service to poorones, a practice that eventually yield-ed to the bureaucratic constraints ofgovernment programs and lack ofequal charity from suppliers of neces-sary diagnostic and therapeutic com-plements. Nonprofit hospitals con-tinue to redistribute in this fashion,reflecting the social mission assignedthem by their constituents and theinsistence of the taxing authorities

that charity care should be the touch-stone for “community benefit.”

Patriotism

Patriotism is a less common sourceof interconnectedness in Ameri-

can health care. America’s commit-ment to tolerance and liberal plural-ism is very effective at creating associ-ational groups with shared values,which in health care spawns agendasas diverse as those of the AmericanCancer Society, the Hemlock Society,Physicians for Human Rights, andthe Association of American Physi-cians and Surgeons. But it is not veryeffective at motivating large nationalprojects during peacetime.

Building loyalty to centralizedgovernments, fostering political sta-bility, and avoiding class warfare—the conventional explanations for thewelfare states of Western Europe—seem unnecessary given our long-standing federal union, our melting-pot heritage, and our belief that con-tinued upward mobility serves as asocial safety valve. Even in post–coldwar America, compulsory redistribu-tion to achieve explicit ideologicalgoals of equality in health care accesssounds disturbingly Soviet (“fromeach according to his ability, to eachaccording to his need”). Accusationsof “socialized medicine,” most recent-ly hurled by former New York CityMayor Rudy Giuliani during his brief2008 presidential campaign, retainrhetorical impact because we contin-ue to fear state intrusion into inti-mate personal and family decisions.

America’s preference for low taxa-tion further discourages a collectivistpolitical orientation. Proposals forgovernment to assume responsibility

for health care are widely perceived asfiscal power plays—schemes not onlyto raise revenue, but also to divertprivate spending on health into other,unspecified government projects.Many Americans suspect that the in-evitable result would be reduced in-vestment in facilities and innovation,quality reductions, supply con-straints, and rationing. These con-cerns are reinforced by the Americanmedical profession—a grass rootsarmy of talented small businesspeoplewho, with fierce conviction if littlehistorical justification, continue toconstrue their social prominence andfinancial success as the result ofrugged individualism rather than

sheltered competition and lavishpublic subsidy.

Nevertheless, patriotism partiallymotivates several core features in theU. S. health care system. Those whorender military service to the nationare repaid in part with health care:the Veterans Health Administrationis the largest component of the De-partment of Veterans Affairs and pro-vides lifetime benefits to millions ofindividuals. The enactment ofMedicare can be viewed similarly, ashealth security to compensate genera-tions of Americans who workedthrough two world wars and theGreat Depression and who becameold and infirm during the sustainedperiod of peace and prosperity thatfollowed. As evidenced by the tempo-ral connection between Medicaid andthe civil rights movement, patriotismto redress prior regional and nationaldiscrimination can also generatehealth solidarity.


The severity of the economic downturn—and the

aggressive response it has provoked—creates an opportunity

to overcome entrenched political positions and recalibrate

public values in support of solidarity.

Coordinated Investment

Athird source of health solidarityis a loosely organized but poten-

tially powerful array of coordinatedinvestments that Americans canmake to safeguard and advance theirfutures. The objective of these activi-ties is to increase overall welfare, notto define citizenship or to redistributeresources from better- to worse-off.Traditional public health functionsfall into this category. Epidemics anddisasters generate widespread willing-ness both to contribute funds and tosubmit to physical restrictions inorder to prevent additional physicalharm and to keep critical infrastruc-ture functioning.

Equally important is reducingspillover economic harm throughprevention and control of noncom-municable chronic diseases—manyof which derive from smoking, poornutrition, and lack of physical activi-ty. Unconstrained governmentspending on chronic disease crowdsout other productive uses of publicfunds. The burden of chronic diseasealso diminishes both near-term work-place productivity and long-termprospects for overall economicgrowth. This collective project is amore controversial exercise of govern-ment authority because, at firstglance, interventions appear aimed atprotecting individuals from the con-sequences of their own conductrather than someone else’s. However,research on social networking revealsthat many chronic health conditionsare “communicable” through sharednorms, and that improved design ofworkplaces, schools, and communi-ties can alter common environmentsand reduce risk factors.

The production of medicalknowledge as a public good is anoth-er established form of coordinated in-vestment, as is support for hospitalconstruction, education of healthprofessionals, and patenting of bio-medical technology (at least follow-ing the enactment in 1980 of theBayh-Dole Act, which encouragedcommercialization of publicly sup-

ported research). Surprisingly, farfewer resources have been directed atimproving the productivity of healthcare providers on the assumption thatprofessional self-governance and mar-ket discipline are sufficient to gener-ate and disseminate best practices.Recently, however, policy-makershave come to understand thatdecades of regulation and subsidyhave artificially fragmented healthcare delivery and rewarded unpro-ductive behavior, rekindling interestin public support for health infor-matics and comparative effectivenessresearch.

A final, widely accepted justifica-tion for coordinated investment inhealth care is the elimination ofwaste. Reducing “waste, fraud, andabuse” in Medicare has maintaineduniversal political appeal for decadeswhile, unfortunately, providing littleactual relief from persistent growth inexpenditures. Today’s proponents oftax-financed universal health cover-age argue, somewhat more persua-sively, that leaving a large percentageof the U.S. population uninsured re-duces access to cost-effective primarycare, wastes expensive emergency ser-vices, and misses opportunities toprevent, detect, and offer timelytreatment for disease. In Texas, for ex-ample, the most marketable argu-ment for health reform among thegeneral public is that roughly $1,500of the annual premium paid by eachinsured family is spent on care for theuninsured. The risk of this approach,of course, is that voter sentimentcould turn from “please spend mymoney more wisely” to “please giveme my money back.”

Policy Implications

Many strands of social solidarityexist in American health poli-

cy, even if an explicit commitment touniversal health coverage continuesto elude us. The severity of the eco-nomic downturn—and the aggressiveresponse it has provoked—create anopportunity to overcome entrenched

political positions and recalibratepublic values in support of solidarity.In my view, however, three barriersmust be removed in order to create amore accessible, affordable, and pro-ductive health care system.

First, federal fiscal politics cannotcontinue to impede collective invest-ment in restructuring health care—an investment that will almost cer-tainly have a large long-term payoff.In addition to funding the marginalcosts of expanding coverage, the tril-lion dollars or so that have been com-mitted as economic stimulus can pro-vide the activation energy (in bothknowledge and infrastructure) neces-sary to transition the health care de-livery system to a new, more efficientequilibrium.

Second, “medical individualism”cannot be allowed to paralyze the de-bate. Americans have built a mentalwall between supporting aggregatechange and resisting personal changethat entrenched interests exploit byportraying every serious reform pro-posal as a threat to one’s own care orthe care of one’s family. Effective re-form must connect individual ser-vices to population health at as manyjunctures as possible.

Third, health is a major compo-nent of America’s long-term credit-worthiness and prosperity in bothour public and private sectors. Indus-try stakeholders must accept thatthose who receive government sup-port in these difficult times cannotmerely continue business as usual,and the general public must agreethat the stakes justify shared sacrificeand require sustained commitment toa common purpose.


Writing in 1780 to his friend Joseph Priestly, theBritish scientist, Benjamin Franklin said thatwith an increase in the “power of man over

matter, . . . All diseases may be prevented or cured, notexcepting that of old age.” The great American Revolu-tionary War physician, Benjamin Rush, was no less utopi-an in prophesying that there will someday be a “knowl-edge of antidotes to those diseases that are thought to beincurable.”

A powerful faith in sci-ence as a basic humanvalue, matched by anequally strong belief inmedical progress, has beena central feature of Ameri-can culture from the start.Although medical researchwas slow in gaining momentum, by the second half of thenineteenth century it was well under way, and it movedforward thereafter at a rapid pace. The establishment ofthe National Institutes of Health just before World WarII, and its steady growth since then, has been a testimonyto an unprecedented congressional bipartisanship andpublic enthusiasm. Some 80 percent of Americans saythey support medical research as a high-priority nationalgoal, and the NIH’s $28 billion annual budget shows it.

The fruits of medical progress—and its first cousin,technological innovation—are not hard to discern. Fromthe near-conquest of infectious diseases by means of vac-cines, antibiotics, and antivirals, to a reduction of deathsfrom heart disease and many other lethal diseases and aresulting increase in life expectancy for almost everyone,it is a faith that has been well rewarded. We are as a na-tion healthier and more prosperous because of it.

Yet it has been, as a value, remarkably little explored,as if its patent benefits putit beyond all inquiry. Anyethical interest has focusedalmost exclusively onbyproducts of the drive forprogress, such as humansubject protection in clini-cal trials and, lately, the use

of embryos for research purposes. Given the massive roleof research as part of our economic, medical, and politi-cal life, there is a good deal more that can be said aboutthe value of progress as a whole, and a number of issuesworth some intense inquiry. Five that have policy impli-cations have caught my eye.

There is, first, the role of research and technologicalinnovation as a main driver of health care costs. Anynumber of economic studies and the Congressional Bud-get Office have identified either new technologies or theintensified use of older ones as responsible for about 50percent of annual cost increases, now averaging an unsus-tainable 7 percent a year. Our technological benefit is


Medical ProgressUnintended Consequences

DANIEL CALLAHAN

Knowledge is limited, whereas imagination embraces the entire world, stimulating

progress, giving birth to evolution.—Albert Einstein

Daniel Callahan, PhD, is senior research scholar and presidentemeritus of The Hastings Center, which he cofounded in 1969.

The pursuit of progress in health care has

led to an unsustainable rise in costs without

a corresponding increase in benefits.

turning into our economic bane.Though only a minority of medicaltechnologies have been assessed forefficacy and a good cost-benefit ratio,they are the front line of Americanhealth care: doctors are trained andwell paid to use them, industrymakes billions of dollars selling them(and resists any cost controls), andthe public loves and expects them.There is, moreover, a profound am-bivalence among many economistsabout technology. They recognize itas the leading economic problem forAmerican health care, but they arefearful of any moves that might harmtechnological innovation.

There is, second, the comparativerole of medical care and backgroundsocial conditions in improvinghealth. Any number of technical esti-mates over the years trace some 60percent of improvements in healthstatus to socioeconomic factors, par-ticularly education and income.Medical care, then, accounts for nomore than 40 percent in general—though the health status of the elder-ly is an exception, and medical tech-nology in particular accounts fortheir improved health in recentdecades. One could make a good casethat improvements in education andjob creation could be a better use oflimited funds than better medicalcare. Social and economic progressmay be the kind we most need, andthat kind of progress would havedouble and even triple benefits be-yond improved health; a good educa-tion, for example, improves both in-dividual health and the economicwell-being of society.

Third, if throwing technology atillness in the name of progress is anincreasingly expensive and economi-cally destructive way to go, whatmight a more sensible idea ofprogress be? My vote would be to aimfor a better balance between cure-ori-ented and care-oriented medicine.The emergence of chronic disease asthe most difficult and expensive kindto manage is demonstrating the fail-ure of cure-oriented medicine to doaway with the nation’s major killers,

which are heart disease and cancer.Patients must now learn, with med-ical help, how to live with and proba-bly die with their condition. By “care-oriented medicine,” I mean not justgood palliative care, but well-coordi-nated medical assistance to managedisease, further coordinated with so-cial and family help.

Fourth, much has been made foryears of the power of disease preven-tion as the best way to save money, tosave lives, and to improve our health.Those are at best half-truths. In theend, sickness and death can be fore-stalled but not conquered, the costsdeferred but not eliminated. Theonly likely way to assure a good out-come for prevention programs is tomake clear to the public that high-cost technologies will be severely lim-ited when the final illness arrives. Thecarrot is that prevention will give us alonger life with a higher quality. Thestick will be the message that youshould take care of yourself and notexpect medicine to save you whenyour time runs out—that is no longeran option.

Fifth, Americans already live, onaverage, a long life of seventy-sevenyears. There is no need to go out ofour way to chase life extension, or thedenial of death, as the sine qua non ofmedical progress. We need progressin removing the health disparitiesthat keep millions from reaching sev-enty-seven, in reducing the social andeconomic burden of disease, and incoping with newly emergent condi-tions (like obesity and asthma in chil-dren) and medical threats (such asantibiotic resistance). The NIH hasalways given priority to the mostlethal diseases, with heart disease atthe top of the list. Increasingly, Iwould argue, our priority should bethe (now) slow way those diseases killus, as well as the diseases and condi-tions that don’t kill us (or not quick-ly) but make life a misery. Poor men-tal health, severe arthritis, frailty inthe old, deafness and vision impair-ment, and Parkinson’s andAlzheimer’s disease fall into that lattercategory.

I mention, finally, two otherplaces where progress is needed. Oneof them is to change the ratio of pri-mary care physicians to subspecialists.Our ratio is now sliding below 20percent for the former and rising toclose to 80 percent for the latter. Afailure to change that ratio (it is50/50 in Europe) will make it almostimpossible to pursue the new goals Ihave identified. The other is to bringthe drug and device industries undergreater economic and medical con-trol. Their idea of progress is an ex-pensive pill or device that will meetmedical needs, and—via the route ofmedicalizing every seen and unseenache, pain, and travail—turn all de-sires for surcease into insistent needs.

Policy Implications

The pursuit of progress in healthcare has led to an unsustainable

rise in health care costs without a cor-responding or equitable increase inhealth benefits. Reexamining its ef-fects should lead to a realignment inthe way progress is valued and to ac-companying shifts in policy. Weshould adopt policies that promotecare-oriented rather than cure-orient-ed medicine; changing the ratio ofprimary care physicians to subspecial-ists is one important step we couldtake in this direction. Further, weshould address social and economicissues, both as an alternative way ofpromoting health throughout thelifespan and to achieve broader per-sonal and societal well-being.

Serious progress would meanturning back the clock: learning totake care of ourselves, to toleratesome degree of discomfort, to acceptthe reality of aging and death (not tomention the near-death experience oferectile dysfunction), and to see ourpersonal doctor as someone as likelyto talk with us as to have us scanned.That cluster of backward-lookingideas is what I think of as common-sense, affordable progress.


Above all values, Americans prize freedom—theright of individuals to control all aspects of theirlives, including the personal and the economic.

In many ways, both major political parties embrace indi-vidual freedom, with Democrats stressing personal free-dom and Republicans economic liberty. What is oftenabsent in political discourse around freedom, however, isthe common good and an appreciation of when rigid ad-herence to individualism is inimical to collective welfare.

A core American value—privacy—is closely linked tofreedom and clearly illustrates the tensions between theindividual good and the collective good. Privacy is afoundational individual good that respects personal dig-nity and protects patients from embarrassment, stigma,and discrimination. Privacy is also a collective good thathas societal value because it encourages individuals toparticipate in socially desirable activities such as biomed-ical research, health care quality assurance, and publichealth surveillance and response. Taken too far, however,privacy can seriously harm activities necessary for thepublic good. Privacy relating to medical records, for ex-ample, encourages individuals to access treatment and

participate in research. However, if taken too far, it canthwart valuable societal activities such as quality assur-ance, cost-effectiveness studies, and epidemiological re-search if essential data are withheld from clinicians, riskmanagers, and researchers.

The prevailing model of privacy, both as formulated intheory and as enshrined in national policy, is doublyharmful. This model purports to safeguard privacy butactually fails to fully protect personal health information.At the same time, it significantly undermines sociallyvaluable activities. President Obama’s stimulus package,the American Recovery and Reinvestment Act (ARRA),authorizes $20 billion for health information technology,which is a cornerstone of the president’s health care re-form proposals. Unfortunately, ARRA and accompany-ing health care reform proposals do little to change thecurrent privacy paradigm and, if anything, reinforce itsflaws.

Privacy and Consent

With regard to health information, the most well-ac-cepted definition of privacy is the right of individ-

uals to control the collection, use, and disclosure of theirpersonal medical information. Thus, individuals retainthe right to strictly limit others’ access to their personaldata. Many scholars and policy-makers even assert that


PrivacyRethinking Health Information Technology

and Informed Consent

LAWRENCE O. GOSTIN

There is a sacred realm of privacy for every man and womanwhere he makes his choices and decisions—a realm of his

own essential rights and liberties into which the law, generally speaking, must not intrude.

—Geoffrey Fisher, Archbishop of Canterbury

Lawrence O. Gostin, JD, is the O’Neill Professor of GlobalHealth Law, Georgetown University; professor of public health,Johns Hopkins University; fellow, Centre for Socio-Legal Studies,Oxford University; and a Hastings Center Fellow.

patients “own” everything to do withtheir body, including human tissue,DNA, future cell lines, and personalmedical records.

The way modern laws and regula-tions assure these entitlements is togrant patients a right to fully in-formed consent. The Health Insur-ance Portability and AccountabilityAct, for example, adopts this modelby giving patients the right to autho-rize most uses of their personallyidentifiable data.

Granting this right certainlymakes sense when the data are to beused for purposes detrimental to theindividual and society, such as dis-crimination in health care, employ-ment, or insurance. However, itmakes much less sense when each in-dividual has the power to withholdinformation needed to achieve com-

pelling public goods such as qualityassurance, cost-effectiveness studies,medical records research, and publichealth investigations—even whenpotential harms to the individual arenegligible.

I propose an entirely differentconception of privacy. Privacy shouldbe understood as an individual’s in-terest in avoiding embarrassing orharmful disclosures of personal infor-mation, while not significantly limit-ing equally valuable activities for thepublic’s health, safety, and welfare.This conception allows that individu-als have an interest in limiting accessto personal data sought by insurers,employers, commercial marketers,and family or friends. But they wouldhave a much-reduced interest in lim-iting the access of those engaged inhighly beneficial, well-defined activi-ties for the public’s welfare.

This would require a fundamentalshift in the way in which privacy is

protected. Instead of relying chieflyon strict individual control of data bymeans of informed consent, it woulderect meaningful privacy and securitysafeguards.

The Failure of Consent

Although consent is a dominanttheme in law and ethics, in prac-

tice it fails to adequately protect per-sonal privacy and is detrimental tovaluable social activities. Multiplestudies have demonstrated that pa-tients do not read or understandcomplex privacy notices and consentforms, which are mostly designed toshield institutions from liability. Pa-tients are also often asked to give con-sent when they are sick and incapableof making complicated decisions.

This means that consent is a poor-ly designed tool to prevent the mostcommon causes of privacy invasion.Most professionals who access med-ical records—such as health careworkers, health plan administrators,and lab technicians—are already au-thorized to do so. At the same time,many of the most visible and worry-ing privacy invasions occur due to se-curity breaches, such as when data areleft on laptops or databases with in-adequate security.

Relying heavily on consent ratherthan on strong privacy and securityassurances shifts the focus frommeaningful safeguards to conceptualand often toothless ones. It providespatients with few real choices andburdens the health system with a newlevel of bureaucracy and expense.Furthermore, the prevailing modelfails to safeguard personal health in-formation both because it leaves gapsand because it is inconsistent.

The gaps in federal regulationleave many patients without protec-tion against privacy invasions. Con-sider the “HIPAA Privacy Rule,”which regulates “protected health in-formation” held by “covered entities”such as health plans and health careproviders. Personal data held bymany entities that are not covered,such as pharmaceutical companies,remain unregulated. At the sametime, the “Common Rule,” whichregulates human subjects research,applies principally to investigationssupported by the federal government.Research carried out with privatefunding is often unregulated. This isin sharp contrast to most other coun-tries, in which privacy regulations arenot limited to particular health caretransactions or funding sources, butinstead apply to all health data.

Federal regulation and oversight ofprivacy is also inconsistent because ofthe marked and confusing differencesbetween the Privacy and CommonRules. The standards for future con-sent, anonymized data, and recruit-ing patients vary under the two rules,leading to contrary results. There isno ethically principled reason for thispatchwork of regulation.

Undermining SociallyBeneficial Activities

Aprimary focus on consent is alsoharmful to the social good. In-

vestigators report a diminished abilityto recruit participants, obstacles inaccessing stored tissue and geneticdatasets, and increased complexity inIRB procedures, causing some hospi-tals and physicians to opt out of re-search. A universal requirement forconsent, moreover, creates selectionbias, which significantly limits thegeneralizability of results and leads toinvalid conclusions.

Rigid understandings of privacyalso hamper quality assurance andpublic health activities. There is alack of clarity about whether privacyand research regulations apply tothese vital activities. As a result, clin-ics, hospitals, and public health agen-


The prevailing model of privacy fails to fully protect personal health information and significantly

undermines socially valuable activities.

cies feel highly constrained when theyseek access to or use personally iden-tifiable health records.

The prevailing conceptualizationof privacy as synonymous with strictindividual control also defies com-mon sense. We all have our own petlikes and dislikes, which is fine if eachdecision only affects the individualmaking it. However, allowing eachperson to make her own decisions inways that disrupt the common goodcauses a deep social problem. Thinkof the consequences of granting indi-viduals a virtual veto over each andevery proposed use of their personalinformation for the foreseeable fu-ture. A patient might say, for exam-ple, that her information can be usedfor research on heart disease but notfor research on AIDS or STDs. Thiseffectively thwarts a great deal ofhealth services research, and the samecould be said for databases used forquality improvement or publichealth.

The perverse effects of privacyrules make life more difficult for in-vestigators, physicians, and agencyofficials charged with carrying out re-search and public health activities.They undermine equally compellingindividual and societal goods: scien-tific discovery, medical innovation,cost-effective health care, and meth-ods of prevention that confront the

nation’s most pressing health prob-lems. These are critical if health carereform is to succeed.

Policy Implications

What is urgently needed is abold approach that would

make federal regulations more effec-tive in safeguarding privacy, moreuniform and fairer in application,and less likely to impede socially ben-eficial activities. A new framework tothe oversight of health records wouldemphasize data security, privacy,transparency, and accountability.Mandated security would includestate-of-the-art systems with securesign-on, encryption, and audit trails.Privacy safeguards would require thatdata be used only for well-definedand legitimate public purposes, withstrict penalties for harmful disclo-sures. Security and privacy proce-dures would have to be transparentand actors held fully accountable. Byfocusing on fair informational prac-tices, patients would gain strong pri-vacy protection, with the assurancethat their personal informationwould not be disclosed to their detri-ment and that data would be protect-ed against security breaches.

To achieve public confidence, thenew system would require carefulethical oversight focusing on mea-

sures to protect data privacy and se-curity, harms that could result fromdata disclosure, and the potentialpublic benefits. An alternative frame-work could also include a certifica-tion for entities that undertake large-scale data collection for definedhealth purposes or to link data frommultiple sources for the purpose ofproviding more complete,anonymized datasets. Federal moni-toring and enforcement would ensureregulatory compliance, and legalsanctions would prohibit unautho-rized attempts to make donors ofanonymized data identifiable again.

Information technology certainlywill be a key component of nationalhealth care reform, but it will fail un-less policy-makers safeguard privacyand facilitate responsible research,quality assurance, and public health.President Obama wants to achieveboth cost-effective health care andstrict privacy. But the stimulus pack-age and his health care reform pro-posals do little to resolve the funda-mental flaws of an antiquated modelfor safeguarding privacy. The successof health reform depends upon ourability to develop as rapidly and com-pletely as possible our understandingof what works in health care, and anawareness that a false sense of privacyworks against that urgent need.


To deem itself civilized, a society must protect thepersonal integrity of its citizens. Without suchprotection, the integrity of the society itself un-

ravels as more and more effort goes into protecting indi-viduals against the chicanery of their fellow citizens. Per-haps this is why Plato called integrity “the goodness of theordinary citizen.”

If integrity is the characteristic value for the ordinarycitizen, then it’s even more important for those whose so-cial roles are defined primarily in terms of personaltrust—doctors, lawyers, ministers, and teachers. Ordi-nary citizens cannot be healed—or provided with advo-cacy, spiritual counsel, or learning—without trust inthese helping professions. (Unfortunately, history re-counts how some physicians in every age have failed inthe trustworthiness integral to medicine.) When suchprofessions lack integrity, those who need their serviceswill seek to protect themselves by assuring greater indi-vidual or public control over their relationships withthese professions.

For a variety of reasons, this is what is happening inmedicine in today’s complex societies—especially nowthat medicine’s power to alter human life is unprecedent-ed. The result is that the center of gravity for individualdecisions has shifted sharply away from the physician tothe patient. That power shift has been reinforced in law

(witness the burgeoning of malpractice lawsuits and in-surance) and public policy as well. However, one mayrightly ask: Is the good of the patient better served whenhe takes charge and directs his own care, or does the ero-sion of trust in the physician’s integrity put the patient indanger of being morally abandoned by the physician?

I contend that autonomy gives patients the moralright to reject care and protects their human dignity, butthat patient autonomy need not interfere with the in-tegrity of the physician—unless that right is expanded insuch a way that patients can demand and even direct thedetails of clinical care. But if autonomy is understood as aright to demand care, it not only violates the integrity ofthe physician, it also endangers the care of the patient.For the benefit of both patient and doctor, patient auton-omy must be understood in such a way that it can coex-ist with physician integrity.

The Nature of Integrity

Classically, personal integrity has been understood as aperson’s commitment to live a moral life. The

woman or man of integrity is honest, reliable, and with-out hypocrisy. He will admit mistakes, be remorseful, andaccept the guilt that follows wrongdoing. The person ofintegrity fulfills the obligations of his private and his pro-fessional life, which are consistent with each other. He orshe follows his conscience reliably and predictably. Thispursuit is intrinsic to the person’s identity. To violate it isto violate that person’s humanity.


Physician IntegrityWhy It Is Inviolable

EDMUND D. PELLEGRINO

Try to become not a man of success, but try rather to become a man of value.

—Albert Einstein

Edmund D. Pellegrino, MD, MACP, is professor emeritus ofmedicine and medical ethics at the Center for Clinical Bioethicsat Georgetown University Medical Center. He also serves aschairman of the President’s Council on Bioethics.

In the patient-physician relation-ship, both parties are entitled to pro-tection of their personal integrity.However, the values, beliefs, andnorms that comprise integrity maywell be very different—and presentdifferent challenges—for doctor andpatient. The physician needs to con-tend with an increasingly pluralisticsociety that can create pressure tocompel him or her to accommodatepatients’ differing religious, cultural,or personal beliefs. Also, the specialnature of the patient-physician rela-tionship (which derives from the factthat being sick and being healed arepredicaments of special vulnerabili-ty), the growth of personal freedomof choice, the systematization of pa-tient care, and the trend toward legalresolution of moral conflicts promiseto increase the demand for personaland/or public control of the physi-cian’s clinical decisions. All these fac-tors encourage erosion of the physi-cian’s personal integrity.

On the patient side, the sick or in-jured person—in a state of distress,pain, and suffering—is compelled toseek out and depend on the physicianwho professes to know how to help.The sick person and his family areasked to make choices among thera-pies, choose when life support maybe discontinued, and decide how vig-orously the terminally ill patient shallbe treated. Throughout all this, thepatient and family must trust thephysician—or more likely a team ofphysicians, nurses, social workers,chaplains, etc.—each offering aslightly different rendition of thechoices. Often, the physician andother caregivers are of differentminds, and none may know what thebest choice is. This uncertainty leadsto lack of trust and may prompt thepatient and family to go in despera-tion from Internet site to Internetsite, and to nontraditional healers ormarginal practitioners, in search ofanswers and of someone they thinkthey can trust. Because, in the end,someone must be trusted.

The Empowerment ofAutonomy

Vulnerable patients have alwaysworried about whether their

physicians possessed the competencethey claimed and could be trusted touse it wisely and well. Until recently,however, they had little power tochallenge the authority and some-times authoritarianism of their physi-cians. Today, we live in a time of self-assertion. Autonomy, the most quot-ed principle of bioethics, empowerspatients to challenge physicians’knowledge and judgment. Patientsnow have the moral and legal rightsto be informed and to give or with-hold consent. Increasingly, patientsand surrogates understand autonomyas empowering them to demand thecare they want. Autonomy has ex-panded to the point that it conflictswith the physician’s moral or profes-sional judgments.

The effect on the physician-pa-tient relationship has been profound

and complex. On the one hand, ithas made that relationship moreopen, more adult, more transparent,and more attentive to the patient’svalues and wishes. Some of the edgehas been taken off physician arro-gance and self-assurance, and the pa-tient’s dignity as a person is better re-spected. These benefits have, howev-er, been accompanied by trends thatare dangerous to the patient and un-just to the integrity of physicians. Forone thing, many physicians feel theyare required to satisfy patient or fam-ily demands or be guilty of “paternal-ism”—the original moral sin of mod-ern bioethics.

To avoid paternalism, some physi-cians and ethicists argue that physi-cians should be morally neutral.

Without sanctioning obvious harm,they should yield to patients whochoose a less effective treatment, or atreatment of no proven use, or evenone that violates the physician’s be-liefs about what is right and good.Furthermore, some physicians believethat in the name of patient autonomythey must protect all confidenceseven when others may be harmed—for example, not reporting the inca-pacitated driver who is a public dan-ger, or not revealing HIV infection tosexual partners. Others may take it asan act of beneficence to exaggeratethe severity of disease or disability toincrease the patient’s insurance cover-age.

More subtle—but perhaps moreimportant—is the physician’s grow-ing reluctance to urge the course thathe or she believes is preferable for thispatient. Despite protestations thatthey know what is best for them-selves, patients do make wrong choic-es. For the physician to suggest other-wise is to fail to respect the trust he

has promised. Refusing to “bias” thepatient’s choice by revealing one’sown choices—and perhaps persuad-ing the patient to change his mind isnot a true violation of autonomy.Rather, not to do so violates the prin-ciples of beneficence and trust.Beneficence does not equal “paternal-ism,” which relies on deception,treating the patient as a child, or co-ercing a choice and is itself malefi-cent. To cooperate in a wrong choiceis complicity with what is wrong, andleaving the patient to decide difficultissues about which the physicianhimself may be uncertain is complic-ity in harm. Rather, what the patientneeds is a physician who protects themoral right of patients to reject anyor all treatment after the options have


Is the good of the patient better served when he takes

charge and directs his own care, or does the erosion of trust

in the physician’s integrity put the patient in danger?

been frankly disclosed, and who willnot use deception or ill-placed em-phases to change the patient’s mind.

Overriding Physician Integrity

The desire for autonomy and un-hindered freedom of choice has

led to law and policy that override thephysician’s objections to certain pro-cedures, including abortion, assistedsuicide, euthanasia, some methods ofassisted reproduction, and embryonicstem cell research and therapy. Thisis not the place to argue the ethical is-sues of these practices. However, re-fusing to participate in them is essen-tial to the moral and professional in-tegrity of many physicians. Manipu-

lating law and policy to make provid-ing them mandatory by threateningloss of license or specialty certifica-tion is an assault on the very personof the objecting physician.

The trajectory of efforts to compelhealth professionals to provide carethey find objectionable is toward re-laxation or abolition of conscientiousobjection privileges. At this writing,there are organized attempts in thecourts to block a new federal regula-tion that protects health workers whorefuse to provide objectionable care.The ultimate goal seems to be toeliminate legal protections of consci-entious objection entirely.

Policy Implications

As we approach another round ofhealth care reform, the medical

profession and the public must to-gether find the balance that preservesboth patient autonomy and physicianintegrity, for the benefit of both pa-tients and physicians. Given how es-sential trust is in medical and healthcare encounters, we cannot trustphysicians who shun responsibility,and we do not want patients aban-doned in the midst of critical healthand medical care decisions. For amorally viable relationship in a dem-ocratic society, both autonomy andintegrity must be sacrosanct.


Amovement has emerged within health care overthe past several decades that sees quality as thecombined and unceasing efforts of everyone in-

volved in health care—professionals, patients and theirfamilies, researchers, payers, planners, and educators—tomake the changes that will lead to better outcomes, bet-ter system performance, and better professional develop-ment; in other words, better health, better care, and bet-ter learning. This sweeping view recognizes that the pur-suit of quality and safety is a dynamic process, not a stat-ic and narrowly focused endpoint. People associated withthe quality movement accept this pursuit as both a moralresponsibility and a serious applied science. They also be-lieve unequivocally that everyone in health care has twojobs when they go to work every day: to provide care, andto make it better—a view that is entirely congruent withthe idea that “unceasing movement toward new levels ofperformance” lies at the very heart of professionalism.

Several centuries ago, the widespread adoption ofcommercial values arguably paved the way for the flower-ing of science. This essay explores the seemingly unlikelyproposition that commercial values have also served asthe principal catalyst for the quality movement in medi-cine when they have come up against the decidedly non-commercial values that medicine has held sacrosanct. Im-proving the quality of health care is likely to be crucial inthe success of health care reform, in part because, like sci-

ence, improvements in quality can bring benefits thatserve as a powerful counterweight to the potentially cor-rosive effects of commerce on professional and social rela-tionships.

Guardians and Gifts, Science and Commerce

Medicine has historically shunned commerce. Untilquite recently, for example, it was not acceptable

for doctors and hospitals to advertise. The admonition to“shun trading” is a key element in what the scholar andsocial critic Jane Jacobs has called the “guardian moralsyndrome”—a code of tightly linked moral values thatgoverns one of the two systems of human survival, “tak-ing” (the other being “trading”). In public life, theguardian moral syndrome, which includes the exertion ofprowess, adherence to tradition, and the dispersing oflargess, is expressed most clearly in government, but alsoin the military and religion—all of which support them-selves through the taking of taxes, tithes, and territory.

Since healers were initially members of a priesthood, itshould not be surprising that from its beginnings, healthcare was essentially a creature of the guardian moral syn-drome. Of course, like everyone else, healers need to putbread on the table. But since they neither taxed nortithed, they were forced to engage in trading. Until aboutfifty years ago, however, they did so on a limited scale; toa substantial degree, they relied instead on nonfinancialrewards from the “gift relationships” inherent in medicalpractice. That is, they relied on deferred and uncertain(but ultimately increased) rewards offered in response to


QualityWhere It Came From and Why It Matters

FRANK DAVIDOFF

Whether for life or death, do your own work well.—John Ruskin

Frank Davidoff, MD, MACP, is editor emeritus of Annals of In-ternal Medicine, and executive editor of the Institute for Health-care Improvement.

their gifts of care and healing. Ratherthan devoting themselves to the im-mediate, calculated exchange that de-fines commerce (such as contracts,investment, capital, and interest),healers felt themselves to be rewardedthrough their high social status, enor-mous respect, and great professionalautonomy.

The underlying moral values ofhealth care in the West changed at aglacial pace, if at all, until about thebeginning of the nineteenth century.That was a time of enormous socialand intellectual change: the latterstages of the Enlightenment, the be-

ginning of the end of slavery, thespread of democracy and republican-ism, the emergence of the industrialrevolution, and the rapid evolution ofscience. Jacobs argues that a major—and perhaps the major—force thatdrove most of these social changeswas the progressive shift from thesmall-scale exchange of goods andservices (much of it in gift relation-ship mode) into full-blown commer-cial enterprises.

Commerce depended for its suc-cess on the assertion of its own moral“syndrome,” which consisted exactlyof the moral values that science need-ed in order to flourish. In commerce,as in science, the questioning ofdogma—dissent—became a virtuerather than a heresy. Likewise, metic-ulous observation, insatiable curiosi-ty, and innovation were prized quali-ties rather than distractions; the gen-eration of new knowledge was recog-nized as a productive investment,rather than a threat; and honesty andtransparency became the bedrock ofmarketplace conduct, for the very

concept of money rests entirely ontrust.

Medicine Becomes aCommodity

The scientific awakening slowlymade its way into medicine dur-

ing the nineteenth century, leading tomany new, more rational, and im-proved ways to care for patients, in-cluding anesthesia, antisepsis, and x-ray imaging. But until about the timeof World War II, the guardian moralsyndrome continued to dominatehealth care’s social values, and explic-

it concern for quality and safety re-mained strangely muted.

Two events that emerged in the1940s were instrumental in prompt-ing medicine to take quality and safe-ty seriously: the discovery of antibi-otics, with their seemingly miracu-lous power to cure humanity’s tradi-tional scourge, infectious disease, andthe evolution of improved study de-signs and statistical methods, whichmade possible the subsequent devel-opment of quantitative clinical re-search. The arrival of potent pharma-ceuticals, plus better ways of docu-menting their effectiveness (not tomention better surgical techniques),led to a sweeping epiphany: whatdoctors do actually “works”! Equallyimportant, most of these dazzlingnew interventions could be separatedfrom the “learned intermediaries”—namely, doctors—who deliveredthem, which made it easier to givethem commercial value and to buyand sell them in the marketplace.

And to be sure, during the pastthirty years, health care has become atleast as much a business as a profes-

sion: patients are now considered“customers,” doctors and hospitalsadvertise product lines, and medicalinsurance companies consider moneyspent on clinical care to be the “lossratio.” The preoccupation with quali-ty and safety in health care hasemerged exactly in parallel with thissurge in medical commercialism. Thecommercial values of comfort, indus-triousness, thrift, and efficiency havebeen instrumental in industry’s devel-opment of an entire science of im-provement and safety that is nowslowly working its way into healthcare. And although it would be hardto prove conclusively that the two arerelated, the striking resemblance be-tween these commercial values andthe Institute of Medicine’s rules forachieving quality—which includetransparency and the free flow of in-formation, continuous decreases inwaste, and customization based onpatients’ needs and values—arguesstrongly for a causal connection.

The Value of Quality

Both commercial and guardian en-terprises are essential in well-

functioning societies: when either haspushed the other aside, the result hasgenerally been disastrous. Consider,for example, the devastation that hasresulted from total government con-trol of economies such as in the Sovi-et Union and, more recently, Zim-babwe; or, conversely, the chaos anddestruction that has occurred whenradical free-market policy has re-placed most major governmentalfunctions, as in the recent history ofIndonesia, Chile, Argentina, andSouth Africa, among other places.Further, the two moral syndromesmust be held together in tension:they cannot be blended together intosome entirely new enterprise, nor canthey be rigidly separated. The only vi-able option then is for the two enter-prises to develop a symbiotic relation-ship that leaves intact the values char-acteristic of each, but at the sametime fosters close, respectful interac-tion between them. This is what hap-


Commercial values have served as the principal catalyst

for the quality movement in medicine when they have

come up against the decidedly noncommercial values that

medicine has held sacrosanct.

pens, for example, when governmentlegislates a goal, such as increased au-tomotive fuel efficiency, but leaves itup to industry to figure out how toaccomplish that goal, whether by im-proving engines, or making vehicleslighter, or developing some other, en-tirely new strategy.

As things stand now, a complexand often contradictory mix ofguardian and commercial moral val-ues is roiling the health care system.For example, the moral obligationfelt by providers to do everythingpossible to meet every patient’s med-ical needs can be seen as a form ofguardian “largess” that supports—and is supported by—commercial in-terest in financial gain, but at thesame time conflicts with the com-mercial values of thrift and efficiency.And the fragmenting effects of com-merce on social relationships can re-sult in distressing “buyer beware” sce-narios. Take, for example, the recent-ly proposed system of consumer-dri-ven care, in which trust in physicians,based on unverifiable assertionsabout the cost and quality of individ-ual physicians’ services, could be con-verted from a purely instrumentalgood into a commodity that wouldbe bought and sold; a marketplace for

such behavior could end up pittingphysicians and patients against oneanother as suppliers and customers.

Policy Implications

For it to be successful, health carereform will need to manage ex-

tremely effectively the tension be-tween guardian and commercial val-ues that currently pushes and pullsmedicine in wildly different direc-tions. If it fails to do so, we are likelyto face increases in the fragmentingeffects of commerce, including in-creases in the damaging effects ofconflicts of interest, particularly inclinical research; worsening of the de-structive drive for “hamster wheel”productivity in clinical practice; andfurther distortion of undergraduate,graduate, and continuing medical ed-ucation under pressures of moneyand time—while at the same time wecould fail to overcome guardian lega-cies such as inefficiency, uncontrolledlargess, and difficulty in respondingto patients’ values and preferences.

But if we’re clever and toughenough to build in “moral syndrome-friendly” interaction throughout a re-formed health system, there’s no

telling how much better off patients,providers, and everyone else mightbe. In fact, the many existing exam-ples of syndrome-friendly interac-tions that support both better clinicaloutcomes and increased efficiency al-ready give some cause for optimism.Thus, pay-for-performance, althoughhardly a panacea, honors the princi-ple of making better clinical “wid-gets,” rather than just more clinical“widgets.” Pragmatic clinical trials arebeginning to provide valuable infor-mation on the comparative effective-ness of new and existing interven-tions, strengthening further the mar-riage between effectiveness and effi-ciency. And exploration of the busi-ness case for quality suggests that bet-ter care can save “dark green dol-lars”—real, bankable savings, that is,not just the “light green dollars” ofpotential, on-paper savings.

Finally, consider patient-centeredcare, a concept that found little sup-port in medicine over the centuries,but that is now emerging as a coreprecept in medical quality improve-ment. It seems right that the long-standing and widely honored com-mercial adage “The customer is al-ways right” is creeping into patientcare. Who would have guessed?


Some major fault lines in the current health reformdebate arise out of conflicting notions about the de-finition and goals of efficiency. There is, however, a

simple and intuitively appealing concept of efficiencythat I believe should be a central virtue of any health re-form effort: To be efficient means to use our resources inthe best possible way to achieve our ends. This makes “effi-ciency” an instrumental ideal—a goal whose meaning de-pends on whatever substantive ends we embrace.

Economics offers some distinctions that can help usthink about our choices. Consider the distinction econo-mists draw between “static”and “dynamic” efficiency. Sta-tic efficiency is a short-run, “at any given moment intime” formulation; it requires that a society operateswithin a given production process as defined by the avail-able technology and organizational systems. Achievingstatic efficiency requires production or technical efficien-cy (ensuring that goods or services are produced at mini-mum cost) and allocative efficiency (ensuring that theright set of goods are produced and distributed to theright individuals). Dynamic efficiency looks at the longterm, but it is not quite so well-defined. It refers to therate at which our capacity to produce outputs improvesover time. Dynamic efficiency requires being efficient inour use of research and development resources in produc-ing new products and processes.

Defining either static or dynamic efficiency requires usto further specify our aims. We do need minimum costproduction regardless of our goals. However, as discussedbelow, we can only decide what to produce (how to be al-locatively efficient) once we specify our goals. Dynamicefficiency requires a trade-off, too, since the more wespend on research today, the less we have to consumetoday—even if we are better off tomorrow. Moreover, ourgoals should determine what new products and processeswe should try to develop, as well as how to trade currentconsumption against future gains. When it comes tohealth policy, two of the most widely used formulationsof “efficiency” incorporate very strong assumptions aboutthose goals.

Two Perspectives on Health System Efficiency

Public health practitioners often define the goal of effi-ciency in terms of maximizing the overall or average

health of a target population. As attested to by Web sitesfull of statistics about overall life expectancy, infant mor-tality, and so on, much discussion and analysis takes thisform. More complicated versions of this approach requireus to develop some complex index—like “Quality Ad-justed Life Years”—that combines the morbidity andmortality consequences of various diseases. There areenormous ethical and practical problems in such a task,since many important value judgments are subsumed inthe process of index construction. For example, how dowe value pain relief versus saving lives, or mental healthversus physical health? How do we value saving the young


EfficiencyGetting Clear on Our Goals

MARC J. ROBERTS

The highest and best form of efficiency is the spontaneous cooperation of a free people.

—Woodrow Wilson

Marc J. Roberts, PhD, is professor of political economy andhealth policy at the Harvard School of Public Health, where hehas taught a course on the ethics of public health policy formore than fifteen years.

versus the old, or the productive ver-sus the disabled?

This view of efficiency is orientedtoward need—toward what expertsbelieve will produce the “biggest bangfor the buck” in order to make every-one healthy. Historically, the roots ofthis view—now often called cost-ef-fectiveness analysis—are in engineer-ing and in the use of quantitativetechniques to improve military oper-ations during and after World War II(what came to be called “operationsresearch” and “systems analysis”). Inthose cases, the goal to be achievedwas specified in concrete terms like“enemy planes shot down.”

The “health/needs” camp includesadvocates of “effectiveness research,”who push for increased use of clinicalprotocols and drug formularies andwho want to eliminate what they seeas inappropriate (and wasteful) varia-tions in patterns of care across thecountry. They believe we could getmore with less if only care was deliv-ered rationally.

By contrast, health care econo-mists typically define “efficiency” interms of satisfying individuals’ desiresto the maximum extent possible.(This implicitly assumes that the ex-isting distribution of income is eitheracceptable or will be “fixed” by some-one else). They seek Paretooptimality—a state in which no oneperson can be made better off with-out someone else being made worseoff. Thus being “better off” is definedin terms of each person’s own subjec-tive level of well-being.

This approach focuses on demand:giving people what they want inorder to make them happy. It is em-bodied in cost-benefit analysis, whichwas developed after World War IIwhen Congress ordered the ArmyCorps of Engineers to limit itself toprojects for which the “benefits ex-ceed the costs.” From the beginning,the task was to value a diverse set ofgains and costs in comparable ways.Not surprisingly, these came to be ex-pressed in monetary terms, based onthe value that beneficiaries placed onvarious outcomes.

Those who advocate for con-sumer-driven health care, higher co-payments and deductibles, and thesubstitution of savings accounts forinsurance are in the “happiness/de-mands” camp. They believe that wecan control costs only if consumerscompare the benefit of more costlyand elaborate care with their poten-tial gains in happiness from, say,more costly and elaborate cars, andchoose accordingly.

In terms of static efficiency, boththe health/needs and the happiness/demands groups favor improvedtechnical or production efficiency.Both also want to be “allocatively” ef-ficient, but they have different viewson what this implies because of theirdifferent goals. This is demonstrated

in their conflicting attitudes towardfostering generic drugs: the “health”camp most wants cost-reducingchanges in practice, while the “happi-ness” camp is content with innova-tion that increases cost as well as per-formance, provided the gains aresomething people will pay for.

Policy Implications

In my view, efficiency in terms ofhealth outcomes has to be a major

concern in U.S. health reform. Wehave the highest health care costs inthe world among industrial countries(between 50 percent and 100 percenthigher than most) and similar—orworse—health outcomes. Withroughly 40 percent of all our costsgoing into nonclinical activities (ad-ministration, sales, paper processing,and profits) we clearly could use amajor improvement in technical effi-ciency. And since there is also muchevidence that we overuse scarce re-

sources in nonproductive ways, wehave major problems with allocativeefficiency as well.

Ironically, both the health careeconomics and public health ap-proaches to efficiency tend to ignorethe distribution of gains. Equity, asthey consider it, is a value that con-flicts with efficiency. But this is an il-legitimate and rhetorical sleight-of-hand that seeks to capture the sociallegitimacy of “efficiency” for thosenot concerned with distribution. Asociety could surely decide that help-ing those who get less care, suffermore, and die younger is especiallyimportant, and then ask, “Are we effi-ciently meeting our goals of makingthe worst off better off?” Indeed, ad-vocates of greater justice within the

American health care system wouldbe wise to focus on what I propose tocall distributive efficiency, since fund-ing for improving equity will alwaysbe limited. We must make sure, forexample, that “safety net” hospitalsthat disproportionately serve the poorare every bit as technically efficient asother hospitals—which, alas, has notalways been the case.

Finally, the biggest health policychallenge facing most industrialcountries at this moment is enhanc-ing dynamic efficiency—finding newways to treat patients that reduce thecosts of care. Aging societies, with in-creasing chronic disease, will face sig-nificant cost pressures for many yearsto come. And the citizens of increas-ingly wealthy and secular societies arealso likely to want more costly healthcare over time.

The only way the impendingavalanche of health care costs can bereduced is if we focus our health careresearch on innovations that decrease


The only way the impending avalanche of health care

costs can be reduced is if we focus our health care research

on innovations that decrease costs rather than on

innovations that drive them up.

costs rather than on innovations thatdrive them up. To do that, we need tocreate a market for cost-reducing in-novations. And to do that, we need tomove from fee-for-service payment(which often encourages the overuseof expensive new drugs and proce-

dures) to bundled payments forepisodes of illness or capitated pay-ments that cover all of a given per-son’s costs for the year. Only then willhospitals and doctors find that effi-ciency—which research shows, ironi-cally, also often produces better clini-

cal outcomes—is in their interest.And only then will our entrepreneursand scientists have an incentive to de-velop those cost-reducing innova-tions, thereby really increasing our ef-ficiency where it counts.


Few dispute the need for health care reform in Amer-ica. Two problems—access and cost—attract themost commentary, and for good reasons. The ranks

of uninsured Americans, which have increased annuallyfor the last six years, are likely to reach 50 million in thiseconomic downturn, and health care expenditures arepredicted to top $2.5 trillion in 2009. Both problems areunsustainable features of American health care. But theseproblems share company with a third that has gone large-ly overlooked. Our health system, if it can be so called, isnot designed to produce health. Indeed, health care is butone determinant of health, and by some measures it is arelatively minor one. Despite the trillions spent on med-ical services, the United States ranks poorly on key mea-sures of health. For example, according to 2004 WorldHealth Association data, the United States ranks forty-sixth in average life expectancy out of 192 nations.

Addressing this gap in our national health reform de-bate requires a fundamental reorientation in our thinkingabout health care and its relationship to health. Reformneeds to include measures that will help keep peoplehealthy and better manage their illnesses should they fallill. We should standardize insurance benefits, refocus ser-vices on primary care, reward the management and pre-vention of chronic disease, create information systemsthat track patient populations, expand community healthcenters. We should also assess (and act on) the health im-

pact of policies in sectors other than health care, such astaxation, agriculture, housing, urban planning, trans-portation, and education. Such reforms will not only pro-duce a healthier nation but also reduce the stark healthinequalities that separate Americans who are better offfrom those who are worse off.

Health and Value

This perspective on health system reform turns on avalue rarely identified, defined, or defended in ex-

plicit terms. That value is health itself. Health is thoughtto be a good in several respects. First, people may valuehealth because it contributes directly to their sense ofwell-being; in this sense, it is an intrinsic good—a goodthat people enjoy for itself. But even if people do not con-sciously appreciate their health when they have it, losingit will make them aware that they rely on some level of itto pursue their interests and to act on their plans. Health,in this sense, is also an instrumental good that enablespeople to manage and control their lives. Health is also acollective social good that can contribute to a nation’s pro-ductivity and reduce absenteeism and health care costs.

Health may seem too simple an idea to define or tooobvious a value to defend in a debate over health systemreform. Questions abound, however, about how to defineand produce it and how to balance it with other values. Ishealth an expansive idea that relates to human well-being,or a narrow idea that relates to bodily function? TheWorld Health Organization defines health as “a state ofcomplete physical, mental and social well-being and not


HealthThe Value at Stake

ERIKA BLACKSHER

A wise man should consider that health is the greatest of human blessings.

—Hippocrates

Erika Blacksher, PhD, is a research scholar at The Hastings Cen-ter and a former Robert Wood Johnson Health and SocietyScholar at Columbia University.

merely the absence of disease or infir-mity.” Critics charge that the WHOaccount is too vague and reduces alldimensions of well-being to health;they define health more narrowly asthe absence of disease. But both ap-proaches involve value judgmentsthat are likely to be contentious.WHO’s definition requires well-de-veloped ideas about the good life; thenarrower, biomedical constructs re-quire consensus on notions such aswhat counts as normal functioningand what counts as suffering. Stillother definitional complexities and

controversies exist. But no matterhow we measure health, the UnitedStates compares poorly to otherwealthy countries and even to somemiddle- and low-income countries.

While we need not agree on a par-ticular concept of health in order toagree that we are an unhealthy na-tion, how we conceive of health hasimplications for how we think aboutimproving it. Because the biomedicalconceptions of health rest on concep-tions of disease and disability, theyrun the risk of channeling our collec-tive attention and action towardmedical services that respond to dis-ease and disability—and away frombroader social systems that preventdisease and promote health. Univer-sal access to timely, high-quality pri-mary care certainly would help to im-prove health outcomes and reducehealth inequalities. But even withuniversal coverage, disparities in dis-ease and injury will remain because ittakes more than health care to ensurehealth. For example, medical servicesmake a mere 10 to 15 percent contri-bution to reducing premature death.In addition, factors that contribute tohealth include health-related behav-iors, genes, and social, economic, andenvironmental conditions.

The pursuit of health equity inthis political culture will have to ne-

gotiate a number of American valueslikely to supply resistance. Onesource of resistance will be those whoview such policies as an infringementon individual liberty. The precisemeaning of liberty may take slightlydifferent forms, depending on thedifferent objections. Policies that banproducts (such as trans fats) or thatregulate activities (such as drivingwithout a seat belt) may be said to in-terfere with individuals’ freedom ofchoice. Others may take aim at gov-ernment programs and the taxes theyentail, based on a principled rejection

of the role of government, save its ac-tivities related to national defense,law enforcement, and judicial institu-tions that protect individual rights.These positions share a concern withwhat people are free from and mayfind common cause with a secondplank of resistance to any robusthealth equity agenda—the view ofhealth as individual responsibility. In-dividuals, not the state, are responsi-ble for improving their health, and ifthey fail at that, it is individuals whomust shoulder the consequences.

Of course, everyone knows of peo-ple who have managed, even againstgreat odds, to change deeply in-grained ways of living and improvetheir health. But many people don’tmanage that, and members of socioe-conomically marginalized and minor-ity groups are disproportionatelyamong those who maintain poorhealth habits. This fact should causeus to rethink and reframe the ques-tion of responsibility and how wethink about liberty. The significanceof class and race for health habitsdoes not suggest that members of so-cially disadvantaged groups are allchoosing in lockstep; rather, it sug-gests that their choices are systemati-cally constrained by living, learning,and working conditions that canlimit people’s choices and perhaps the

freedom expressed in those choices.Policies that remake these social con-ditions—for example, ensuring thateveryone has a nearby grocery storethat sells fresh produce, a primarycare physician, a pharmacy, and safevenues for recreation and social gath-erings—can enhance people’s free-dom to make healthier choices. Sosome forms of collective action canenhance people’s liberty.

That these social conditions areoften the product of widely endorsedpublic policies suggests that the callfor personal responsibility should beaccompanied by an awakening of oursense of shared responsibility. Theidea is not foreign to U.S. politicalculture; indeed, it seems to be at thecenter of our new president’s philoso-phy. President Barack Obama hascalled for a “new era of responsibility”that makes demands not just of indi-viduals, but also of families, commu-nities, and society at large. This big-tent conception of responsibilityshould be directed at promotinghealth for all.

Policy Implications

The social determinants of healthare particularly salient in this era

of chronic disease, whose causes canbe traced to the conditions in whichwe grow up, live, learn, work, andplay. Health habits related to diet, ex-ercise, and tobacco use make an in-disputable contribution to the onsetand progression of chronic diseasesand help explain some of the dispro-portionate disease burden amonglower socioeconomic groups. Buthealth habits do not explain all of it.Low socioeconomic status itself con-tributes to premature mortality andexcess morbidity. Researchers do notyet know which markers of class exertthe most profound influence onhealth, but low educational attain-ment, low-wage jobs, poor-qualityhousing, and polluted and dangerousneighborhoods, along with the stressand social isolation these experiencesmay induce, all plainly play a role.The vagaries associated with being


Health care is but one determinant of health, and by

some measures it is a relatively minor one.

poor or near poor exact an especiallyheavy toll on the health and develop-ment of children, often with lifelongeffects.

If the organizing principle ofhealth reform is the production andthe fair distribution of health, thenwe will need to rethink what a healthsystem is. What might such a systemlook like and what sort of policieswould it entail? Promising policiesand programs have been recom-

mended, and some are already beingimplemented in states and citiesaround the country. These interven-tions include measures aimed at sev-eral different levels. Some focus onneighborhood conditions: they seekto improve housing stock, create safeareas for exercise, and enhance thefood supply (such as by banningtrans fats and by supporting farmers’markets, for example). Other inter-ventions focus on at-risk families and

children, by providing income sup-ports, securing nutrition, and enrich-ing educational environments andopportunities. Yet other possible in-terventions promote educational at-tainment and improve work condi-tions and benefits for adults. Thesemeasures cannot guarantee health forall. But they can promote a fair op-portunity for health for all. And thatis a very American value.


To exercise stewardship, or not—that is the ques-tion. Why put the point that way? Because onepath leads to an abundant life, and the other is a

dishonest, if elaborate, form of suicide.Stewards distinguish themselves first by accepting re-

sponsibility, and then by acting on that responsibility topreserve, protect, and nurture something precious,through recurrent threats, for the purpose of deliveringthat precious thing to future generations.

Who may confer and who must accept responsibilityfor stewardship of our health resources and the health ofour population?

Some libertarians today argue that society is a myth,that no one has responsibility for the outcome of hun-dreds of millions of health-related decisions, and thatanyone who asserts such responsibility and tries to actupon it is both an arrogant tyrant and an existentialthreat to the essential freedoms upon which our nationwas founded. Nothing (and no tiny group of argumenta-tive people) has ever been more profoundly wrong.

Thomas Jefferson, that true student and teacher of lib-erty, amended John Locke’s famous trilogy (life, liberty,and estate) and wrote that all people have an inalienableright to life, liberty, and the pursuit of happiness. Jeffer-son also wrote: “Liberty is to the collective body, what

health is to every individual body. Without health nopleasure can be tasted by man; without liberty, no happi-ness can be enjoyed by society.” What does the right tolife mean if one does not also have access to known andwidely available life-preserving and life-enhancing diag-noses and treatments? How can one meaningfully pursueany individual definition of happiness if one cannot af-ford essential care for a sick child, a breadwinner, or a dis-abled spouse or parent? In short, what is life and happi-ness without health?

At the same time, what is happiness if “too much” ofyour hard-earned income or wealth is taxed away, even itis taxed to pay for the critical needs of others? Especiallyif “too much” is defined subjectively (as it must be in theend), based on one’s personal understanding of the facts?

Crisis and Covenant

For an unusual but very helpful way of answering thesequestions, put recent work by the Institute of Medi-

cine alongside some ancient teachings in Leviticus, thethird book of the Torah and of the Old Testament in theChristian bible.

The Institute of Medicine’s 2009 report, America’sUninsured Crisis: Consequences for Health and HealthCare, affirmed and updated its 2002 conclusion thatroughly twenty thousand Americans die every year be-cause they do not have access to routine but efficaciouscare because they lack health insurance. This means thatover the fifteen years since we stopped debating the Clin-ton plan for comprehensive health reform, we have lost


StewardshipWhat Kind of Society Do We Want?

LEN M. NICHOLS

...and the call for Stewardship of the collective resources…is clear ...

—Thomas Aquinas

Len M. Nichols, PhD, directs the Health Policy Program at theNew America Foundation. Previously, he was the vice presidentof the Center for Studying Health System Change, a principal re-search associate at the Urban Institute, and the senior advisor forhealth policy at the Office of Management and Budget.

three hundred thousand of our fellowcitizens to our collective failure to en-sure coverage for all. No one doubtsthat the main reason the vast majori-ty of the uninsured lack coverage iscost. That is to say, we effectively ra-tion care—and life—by income, andevery student of and participant inour health care system knows it.

Chapter 23, verse 22, of Leviticusadmonishes the landowner at harvesttime to leave a bit of the crop in thefield so that it may be “gleaned” bythe poor and the alien. Later bookswritten by Moses and by laterprophets (as well as the Qu’ran) usedthe more frequently taught and re-membered formulation, “widow, or-phan, and stranger.” Why was feed-ing the hungry such an important ad-monition? Because otherwise thoseon the fringes of community mightstarve, having no established propertyright to food (you had to be an adultmale to own land in ancient Pales-tine)—and preventable starvationwas simply unacceptable. It violatedthe sacred covenant with God. Everyhuman being was made in the imageof God and therefore had the right toparticipate in the life of the commu-nity—the right to life. Landownerswere called to be stewards of theirown “estate,” and of the fruit of theirlabors (in Locke’s sense), so that noone would starve, even those who didnot share family, tribal, or even reli-gious connections. Even in America,where social solidarity is nowherenear prophetic or even Europeanstandards, we have food stamps andfood banks. We honor the ancientcovenant to feed the hungry in everycommunity.

Health care has become like food.It is a unique gift, capable of sustain-

ing and enriching lives stricken withillness. Since all of us could be strick-en with serious illness, since all of uscould lose our job and our insurancetomorrow, all of us are also potential“strangers,” which is to say that ourcommitment to the covenant is ulti-mately self-interested, as it was inbiblical times. That does not make itless sacred.

At the same time, it is importantto read the call for stewardship im-plicit in Leviticus carefully. Leviticusdoes not say to bring the poor homeand cook for them; it says, Leavesome of the harvest in the field forthem to glean. Our oldest obligationshave always been mutual: it is per-fectly and morally acceptable to ex-pect personal responsibility from thebeneficiaries of our covenantallargess.

Leviticus also does not say to leaveall the food that one poor personmight want, nor does it admonishthe landowner to make sure that

everyone has the exact same amountof food. Leviticus expects thelandowner to exercise stewardshipover his resources so that his own self-interest is preserved, as well as thefundamental requirements of fellow-ship within the community. That iswhat stewardship is: leaders have totake care to set rules and make keychoices to prevent imbalances thatwould lead to unacceptable out-comes, such as some being left out al-together or the land being over-worked or abused and losing its pro-ductive capacity.

Policy Implications

Mapping this ancient lesson ontostewardship requirements for

our health care system seems straight-forward to me. Political, economic,and health system leaders—the“landowners”—must make sure thatour system serves all of us at a basiclevel (and not just all Americans, but


The Gleaners, by Jean Francois Millet

That is what stewardship is: leaders have to take care to

set rules and make key choices to prevent imbalances that

would lead to unacceptable outcomes.

all residents and visitors, if you inter-pret “stranger” in the Biblical sense,as I am recommending). At the sametime, rules and choices must be madeso that the system will be sustainableover time, and thus able to serve all ofus in the future.

Those rules include restructuringinsurance markets to make themboth fairer and more efficient. Weshould require all insurers to end dis-crimination based on health statusand all individuals to purchase insur-ance (or enroll in a public programfor which they’re eligible). The choic-es include a sliding scale subsidyschedule that ensures affordability,

and reforming payment structures inthe Medicare program to realignprovider incentives so that they en-gender a far more efficient deliverysystem. The savings from this, plusreducing the current regressive taxsubsidy for employer-provided healthinsurance, should be enough to makeour financing and delivery systemssustainable over time.

Changing the system along theselines will likely require constant re-evaluation of system performance inaccess, quality, and cost dimensions.At the moment, spending 16 percentof the national gross domestic prod-uct (almost twice the average in de-

veloped nations) yet leaving 16 per-cent of our population out of the sys-tem (while other developed nationstypically include all of theirs) is primafacie evidence that our system needs afundamental realignment of incen-tives and redistribution of accessrights. Such change simply cannot beafforded, however, unless we also si-multaneously undertake an effortakin to the “parting of the waters” toimprove the efficiency of our healthcare system. This will not be easy, butthe payoff in social cohesion will beworth it, and the ancient admonitionof stewardship demands no less.


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