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Living Well, Dying Well

July 16, 2009

The debate about health care reform in the United States boils down to three fundamental problems that afflict us collectively:

  1. We don’t live well.
  2. We don’t die well.
  3. And we spend too much time, talent, and money doing both of these things badly.

Even if liberals and conservatives could somehow find common ground in this definition of the problem, they would probably still arrive at radically different conclusions about what to do about it.  Here’s a starting point for their discussions, though: What duties do individuals owe one another, especially in terms of their mutual health and happiness?

It would not be an oversimplification to say that human beings have constructed entire religions and philosophies in the quest for answers to this question.  In doing so, each has tried in its own way to address the three issues at the heart of our current dilemma with health care.

Each of these efforts has concluded that we all have to accept a measure of personal responsibility and accountability for the choices we make.  Likewise, every major religious or philosophical doctrine concludes that we owe some duty to others, even if only to avoid doing anything that would knowingly harm them or prevent them from pursuing their own best interests as they see fit.  Most doctrines go a step further though and promote a general duty to act beyond one’s own interests, to give something more for the benefit of others without expectation of reciprocity.

This is where the living and dying parts come into play.  Framing the health care debate in terms of the value of human life as if it were a commodity overlooks the fact that how we die often has as much if not more meaning than how we choose to live.  An efficient and effective health care system must not only help people enjoy health and happiness, but it should also help them make better decisions about their care in terms that address the impacts of their health choices on others.

To a very great degree, the health care debate frames the decisions before us in strictly utilitarian terms, and assumes that left to our own devices most of us would choose to pursue our self interest at the expense of others.  An abundance of evidence suggests we often behave otherwise, even when our actions seem irrational to others.

I would like to think that a more egalitarian approach, one that affords people an opportunity to choose not only the health care options that best suit them, but also to consider how their choices affect others’ options could advance us toward a consensus.  It has been my experience that people not only will, but often do, give of themselves when they see investments in their treatment not in terms of cost or extended quality of life but in terms of the opportunity cost of depriving  others of the enjoyment of these same benefits for themselves.

Put another way, how many of us would choose not to receive costly treatment for a terminal condition, which would afford us a very small chance only of extending our own life a few weeks or months, rather than giving dozens of others greater access to early detection and treatment of the same condition?  This is no hypothetical example.  Many health care systems around the world already operate on this premise, and the hospice movement, living wills, and advance directives represent organized and growing efforts in this country to institutionalize exactly these sorts of values.

Efforts by politicians and health advocates alike to address the dilemmas affecting access and cost of delivering quality health care in this country should consider carefully how they can frame the choices before us in a ways that avoid oversimplifications while appealing to better angels of our nature.

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