For years I have made the point that the key problem with discussing our so-called health care system is that we don't have one. The system focuses mainly on taking care of people when they get sick. It's a sickness care system. This system ends up producing two things: more sickness and ever-increasing costs. This makes sense, since the people who own and work the system mainly derive their income from sick people.
Think of the old Maytag commercials, featuring a Maytag repairman with too much time on his hands, because Maytag washers rarely break down. The manufacturers could afford to make a joke of his idleness. Demand for their products didn't depend, in the first instance, on mechanical breakdowns, but on the endless supply of dirty clothes. But the sickness care sector is rather like the repairman. Its income depends on the possibility and frequency of breakdowns.
Unlike the demand for washing machines, however, the demand for a properly functioning human body doesn't rise in relation to some other product. The body has an intrinsic value, like the human being whose existence in this world depends upon it. But just as they take existence for granted until it's threatened, people generally tend to take the body for granted until it's ailing. Then they seek the services of someone who can restore its proper functioning. This obviously complicates the incentives of the person who has the necessary expertise. Though he gets paid to make people well, they are by and large only inclined to seek his services when they get sick. In which does he have the greater interest, their sickness or their health?
Considered simply as a matter of selfish calculation, the medical expert is likely to profit most from a situation in which people who are prone to get sick see him as the source of a sure and effective remedy for what ails them. As Socrates points out from time to time in the Platonic dialogues, this leads to a dangerously ironic situation for his potential clients. The medical expert has the knowledge to cure them, but he may also have a strong motive to use that knowledge to make sure they don't stay healthy. Oddly enough, the result would correspond to the one we've been getting from our sickness care system- people clamoring for what they perceive as effective care while overall becoming more and more susceptible to disease. Meanwhile, budgets are strained as more and more money flows toward the sickness care sector.
Of course in ancient times this result was not as pronounced as it is today because medical experts weren't so good at dealing with sickness. Once someone got sick, the experts soon reached the limits of their ability to do more than palliate his suffering. The techniques of modern science have produced breakthroughs in sickness care that allow contemporary experts to do a better job of treatment in many areas, particularly those susceptible to surgical intervention or the use of antibiotic drugs. But this success has produced another less desirable result: medical expertise that focuses on sickness. Because ancient experts were less successful at dealing with sickness, they put greater emphasis on keeping people healthy. They focused more attention on understanding the dietary and exercise regimens that increased health and vigor. Though pain relief and sickness cures certainly played a role in their livelihood, the best advertisement for their wisdom was the strength and health of the people who followed their advice, not the excited praise of those they cured of disease.
More limited knowledge led to greater humility. They ascribed miracles cures rather to divine power than their own sophistication, which gave their profession a tinge of something more akin to religion than what we today would call science. Medical experts were seen as followers of a divine path or way, with a mystical component that also addressed the issue of trust implied by the double-edged quality of their motivation. They were oath bound not to follow the promptings of cynical calculation, and therefore to place the good of their patient above their own selfish advantage. These days we still assume the existence of this moral framework. Given the elite embrace of moral relativism, and its quiet contempt for religious truth, God knows why we do.
Be that as it may, these reflections help us to understand the fatal flaw in the present debate over the future of the medical services sector: it takes a deceptive rubric of analysis as the basis for discussion. This is due in part to the deceptive language characteristic of the discussion. We talk about access to health care, when sickness care is the real product. Terrified by the economic implications of its rising costs, we tacitly accept the deadly necessity for rationing, now going so far as to propose targeting the elderly and infirm to bear the burden of budgetary constraints. Suspecting the profit motives of those who own and work in the sickness care sector, we are also increasingly tempted by socialist proposals that would enslave them to our needs, allowing us to keep costs down by dictating the terms of their remuneration. Meanwhile, we neglect even to discuss the true source of the cost push- which is the rising tide of sickliness (preoccupation with disease), that increases the demand for sickness care despite the much touted breakthroughs of medical science.
I have long argued that we won't arrive at, or even conceive of, approaches that turn the situation around until we reject the assumption that sickness care is an acceptable product for the health services sector. The rubric and aim of health services should be health. The measure of success in the health sector must cease to be the amount, distribution and financing of treatment for sickness. Instead, we should focus on what keeps more people healthier for longer periods of time; what strengthens them in mind and body; what feeds and encourages their will to live, and their understanding and implementation of the discipline needed to serve that will effectively.
This amounts to a Copernican shift in the way we conceive of and analyze the health sector challenge. Tomorrow I'll outline a number of relatively simple and straightforward goals that come into focus as a result of this shift, goals that provide a basis for a true revolution in the meaning of, and provision for, our society's health concerns. The key to that revolution is responsible, individual freedom, not a socialist takeover.