The Commodification of Health Care
By Bernard Lown, MD
PNHP 2007 Newsletter
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Dr. Bernard Lown, MD, a cardiologist who invented defibrillation and many other innovations in cardiac care, is professor emeritus at the Harvard School of Public Health and Senior Physician at the Brigham and Women’s Hospital, Boston. He was co-recipient of the Nobel Peace Prize 1985, on behalf of the International Physician for the Prevention of Nuclear War (IPPNW) which he co-founded.
Health care in America is in deep crisis. A public service has been transformed into a for-profit enterprise in which physicians are “health care providers,” patients are consumers, and both subserve corporate interests. The effect has been to convert medicine into a business, deprofessionalize doctors and far worse, depersonalize patients.
In my lifetime in medicine, now spanning 50 years, I have witnessed a remarkable transformation. From a healing occupation dominated by professionals, medicine has increasingly become an industrial process run by technicians.
Underlying the breakdown of the health care system is a far deeper phenomenon - the onrushing marketization of all human transactions. The over all impact is to denature fundamental human values and tear apart the ties that nurture communal life. Yet no such profound developments are without opportunities to mobilize people on the basis of their most intimate undermined self-interest. What is happening within the medical system affords a profound education for the public on a much wider issue; the fundamental flaws of a market-driven consumer society.
In less than two decades, health care for a majority of American’s was brought under control of what is called managed care, run by large insurance companies. The growth of fully privatized Health Maintenance Organizations (HMOs) was spectacular, increasing from 12% of those covered by private insurance in 1981, to 80% of the 200 million covered in 1999. The proffered rationale for the sweeping corporatization was the need to contain health care costs, founded on the belief is that only competitive, investor-owned organizations have the financial discipline to stem the inflation of health care expenditures.
Until the advent of HMO’s, health costs were rising, on average about 11% annually - three or more times the rate of inflation. In 1995 American health expenditures for the first time surpassed $1 trillion dollars per year. In Massachusetts where I live, with a population of 6.1 million, total spending for health care last year was over $50 billion dollars. This exceeds the health budget of India and is nearly equal to that of China, the most populous nations on earth. Many establishment economists have maintained that the USA cannot afford to invest 16% of its gross national product (GNP) on health. The stated reason for governmental encouragement of the private sector is to contain such mounting costs.
However, no major social transformation results from a single cause. The change in health care could not have happened without a multiplicity of forces working together. In my view, these include: the medical scientific and technological revolution; an altered conception of the meaning of health; the attending changes in the doctor patient relationship; growing patient dissatisfaction with a depersonalized system; the demographic transformation brought about by an aging population; the huge profits to be made; and the insatiable appetite of corporate America.
The Scientific-Technologic Revolution
Colossal medical achievements characterize our era. People residing in industrialized nations no longer need fear succumbing, unexpectedly, to dreaded pestilence. The introduction of sulfanilamide, in the mid 1930’s and penicillin during the last stages of WWII wrought a health care revolution and contributed to a demographic transition. Infectious disease, the leading cause of global fatality, could be contained. The most telling single statistic - embodying scientific advances - is the expansion of the human life span by an average of 25 years since the beginning of the 20th century. People not only live one third longer, but are far healthier, and their state of good health is maintained into ripe old age. According to the ancient Greeks, upon reaching the age of 50, one entered the senescent phase of life. At present, it is not unusual for a septuagenarian to continue gainful employment, partake of travel, sports and other vigorous activities.
Science has improved human life during all of its stages. The fetus can be monitored from near conception, prematurely delivered when in distress, and kept miraculously alive when weighing less than a kilo. Numerous congenital abnormalities no longer need shorten or disfigure life. Defective organs, be they hips, hearts or livers, when beyond repair, can be replaced. Many cancers can be restrained in their wanton proliferation, and a cure for many of the malignancies is in the offing. Coronary artery disease, the major cause of premature death in industrialized societies, is now being defanged as its pathogenesis is increasingly comprehended. I am optimistic that within the next decade this massive affliction will be controllable as well as largely preventable.
But science is not all pluses. Three essential adverse consequences will be touched upon. First is the presumption of medicine as merely a science, reducing human beings into biomedical models with physicians serving as superspecialized technologists; second is the short shrifting of social and psychological factors as playing a role in disease; and third is the distancing of doctor from patient and patient from doctor.
Science Contributes to Abandoning Healing
The practice of medicine has increasingly shifted to a scientific paradigm which approaches the patient as a biomedical being. Medical students are selected based on their achievements in pre-medical science course, not their affinity for the humanities nor their readiness to serve people. The medical school curriculum responds to the promises of science by progressively diminishing training in interpersonal relations. Little time is devoted to mastering history-taking or acquiring skill in the physical examination. Training is focused on proficiency in science and gaining competence in a host of technologies and procedures. Students are inculcated with a reductionist medical model in which human beings are presented as complex biochemical factories. A sick person is merely a repository of malfunctioning organs or deranged regulatory systems that respond to some technical fix. Within this construct, the doctor, as exacting scientist, uses sophisticated instruments and advanced methods to engage in an exciting act of discovery.
The fact that doctors are trained largely in tertiary care hospitals, veritable emporia of cutting edge technologies, further conditions the young with a mindset favoring the technical. This is reinforced by their teachers, future role models, who are almost exclusively highly trained specialists. Bedside teaching rounds are largely replaced with chart rounds and examining computer print-outs of the latest laboratory data. On rounds, attending physicians evince scant interest in the sick patient and instead fixate on the biochemical, molecular or genetic derangements. The focus of teaching necessarily shifts from an holistic approach dealing with an ailing person to the dysfunctional organ. Human interactive skills are deemed outmoded and are minimally cultivated. The patient is increasingly referred to not by name but by the deranged organ as the liver, kidney, heart patient or whatever ails.
What in olden times could only be exposed by pathologists during a post mortem examination, can now be imaged speedily, accurately and safely. No structure is hidden from view. Young doctors glory in being scientists with a commitment to master these sophisticated instruments and complex methodologies. The trainee physician quickly learns that compared with the sharp images provided by ultrasonography, MRI, CT, endoscopy, and angiography, a patient’s history is flabby, confused, and subjective. Being deskilled in bedside medicine, young doctors have but little choice in dealing with patients except to rely on sophisticated medical gadgetry. There is no consideration of the prohibitive economic costs of immediately resorting to expensive technologies and bypassing the patient who is the ultimate repository of relevant information.
Contributing to the popularity of specialization is that early in their careers doctors learn that ascent on the academic ladder is for those who master these elegant technologies, not for those who evince interest in afflicted human beings.
This trend is reinforced and accelerated by the billions of dollars poured by the government into medical research. The physician most gifted in obtaining grant funding is promoted in academe. Advance is unthinkable without a thick bibliography and success in obtaining grant support. Prestige no longer belongs to a beloved family physician nor to an astute bedside clinician, but is the prize for those who breach the scientific frontier.
Not only contemporary philosophic notions of illness, but powerful economic incentives reinforce these views. The shift from a patient-focused health care system to one based on disease, relates to lucrative fiscal rewards for the practitioners of scientific based medicine. Reimbursement is greatest for the specialists who are captains of complex and invasive technologies; cardiologists foremost among these. Society places a far higher premium on using technology than on listening or counseling. A doctor earns more from performing a procedure requiring a single hour than from an entire day spent communicating with patients. The following fact is illustrative. In 1982 U.S cardiologists earned $127,000 annually. By 1987, their income had nearly doubled to $225,000 coincident with the introduction of coronary angioplasty, which is pursued with ideological fervor though supported by scant evidence that it prolongs life or protects against a heart attack.
The enormous appeal for specialization skews the distribution of doctors. Unlike any other country, 70 per cent of practicing physicians in the U.S are specialists. Another lesson of the American experience is that a medical care system skewed towards science-based, curative medicine entrusted to highly trained specialists, costs grows astronomically and health care is increasingly rationed along class lines.
Scientific medicine that ignores the ailing human being has additional negatives. It leads to the medicalization of people and thereby warps the social fabric in numerous ways. Government funding of medical research requires an enthusiastic public. Every medical center dependent on such government largesse has a public relation staff generating a continuous Niagara of information about this or that scientific break-through or medical miracle. The bottom line message to the public has been that scientific medicine has a potential cure for all that ails. The massive medical industrial complex in the USA, now far larger than the military, further contributes to the hype since it needs to cultivate an ever growing number of customers for its expensive wares. It enfilades the media with stories about health and the value of its commercial products. Pharmaceutical conglomerates, major players in this game, currently advertise directly to the public - to the tune of $2.7 billion in 2001. In a complete reversal of norms of medical practice, these advertisements urge people to recommend a particular drug to their doctors. In fact, patients may be among the first to learn the merits, but rarely the limitations, of a newly released drug.
As Ivan Illich predicted in Medical Nemesis, medicine has expanded into almost all facets of human existence. Brought into the domain of medicine are an array of “proto illnesses” - conditions that do not cause symptoms or impair life in any way but are prognosticators of potential illness far in the future - are brought into medicine. Among this ever-mounting list are such conditions as high blood pressure, elevated blood sugar, cholesterol levels, osteoporosis, colonic polyps, heart murmurs, carotid artery narrowing, memory loss, sun exposure, and the list is constantly expanding. As scientific insight advances one may reasonably anticipate the emergence of a whole gamut of tests predictive of potential disease. Furthermore, it is certain that risk factors for future illness will be recognized ever earlier in life - soon, at birth, in utero, and with genetic mapping even before conception.
A recent study highlights the problem with this approach. At the National Institute of Health, 1000 healthy asymptomatic individuals had brain screening with magnetic resonance imaging. Of these, 18% demonstrated incidental abnormal findings and three were found to have unsuspected brain tumors. Should then the entire population be screened, and why only the brain? The negatives of such sweeping dominance of medical science are evident. Everyone is tied umbilically from birth to the medical establishment, resulting in an unceasing preoccupation with the struggle of surviving rather than with the challenge of creative living.
I harbor even deeper misgivings about the biomedical model and the current dominant scientific paradigm in medicine. This model, rooted in Cartesian dualism, is now under serious philosophical challenge. Science is fundamentally reductionist; it orients to probabilities not certainties, it searches the very depth to focus on genes and molecules, on electrons and subatomic particles. Defining a complex amalgam - such as an individual - is beyond its purview. But the practice of medicine ultimately is focused on the individual.
The biomedical model is additionally challenged by the theories of chaos and complexity. These theories question the basis of determinism as the explanation for cause and effect. They suggest that small, barely perceptible initial conditions of a system can result in disproportionately large changes in the same system over time, and emphasize the limitations of a reductionist approach in describing natural phenomena. The implications are that some systems are unpredictable and will remain so. Traditional science cannot accurately predict the trajectory of complex systems such as people. Physicians face a sea of uncertainty in dealing with a particular human being, confronting a system with an infinitude of interacting variables shaped by familial, cultural, social, and economic factors, condimented with conditioned responses and inundated with subconscious mental content— virtual memories of the night. The extant medical scientific vocabulary is dismissive of these “unknowables,” communicating a largely irrelevant and nonexistent degree of determinism.
For physicians and patients, the building blocks of communication are metaphors and narratives, the ancient tools for comprehending the world. They enable coping with the subjective and the unmeasurable; the prevalent depression among the elderly; the grief of the bereaved; the suffering of those with terminal illness; or the despair of a mother with a dying child - all of which the physician is committed to assuage. Listening with care to a human narrative provides insight to emotional complexity and permits a glimpse into the mind of another, indispensable to the act of healing. When these are ignored, as they are in scientific-based medicine, patients feel abandoned with dire consequences for patients as well as the profession.