Letters

The Great Awakening: How to Accomplish the Reform That Justice Requires

To the Editor:

I commend the members of the Ethical Force Program for their work in the essay "Improving Access to Health Care" (Sept-Oct 2007) They have articulated fair and reasonable criteria for assessing health reform proposals from an ethical perspective that reflects significant consensus. I hope their work can be widely disseminated to the American public.

I want that term "disseminated" interpreted in a richly participatory sense. If all Americans were to read this essay and think "I agree 100 percent with these ethical criteria for assessing efforts at health reform," the predictable result would be changes in our health care system that were minimal, marginal, myopic, and muddled. This says nothing about the moral ineptitude of the American public; it says much about the power of the nonethical forces that will likely shape the actual substance of any legislative reform effort (as opposed to the moral sentiments that will decorate that effort).

We need to keep two things vividly in mind: first, the health care sector of our economy in 2007 represents $2.3 trillion worth of business; and second, the need for setting limits fairly and rationing fairly must be part of any health reform effort. Uwe Reinhardt, a distinguished health economist from Princeton, has often reminded his audience of the Great Equation: Health Care Cost Containment = Health Care Income Containment. We currently do 62 million CT scans per year in the United States, which represents about $30 billion in health costs. One-third of those are estimated to be not medically necessary, which means we could glean $10 billion from there for meeting the serious health needs of the uninsured. It also means we would have to take $10 billion in income from radiologists.

Dozens of these major cost-access and cost-income trade-offs will have to be made to achieve the significant reform that justice requires. The extraordinarily costly cancer drugs I wrote about in the Hastings Center Report ("The Costs of Caring: Who Pays? Who Profits? Who Panders?" May-June 2006) would be another likely focus for setting limits that would yield billions in savings (and billions in lost income to pharmaceutical companies). One large reason why the Clinton health reform effort was defeated in 1994 was that these interest groups saw themselves as economic losers in a proposed reform effort and worked assiduously to sink the legislation. No amount of public ethical enthusiasm for reform was going to be sufficient to hoist the hundreds of economic anchors that held the health care ship in place. This brings us back to my introductory point.

Intellectual affirmation of all of the ethical criteria for reform articulated by the Ethical Force Program will accomplish nothing. What we need instead is a Great Awakening of the democratic spirit in the form of democratic deliberative practices that articulate a health care covenant to which we can all be loyal. That covenant must express our commitment to being a just, caring, and inclusive society in which we share the benefits and burdens of a technologically advanced health care system fairly—in other words, mutual sacrifice for mutual benefit.

This covenant must be a product of a sustained national democratic deliberation, not a few scattered town hall meetings. It must be a product of honest, respectful dialogue about extraordinarily controversial issues, not ideological rants on talk radio or insulting blogs on the Web. This Great Awakening must include recognition that the income and profits we expect radiologists and pharmaceutical companies to forego ultimately represent marginally beneficial, excessively costly CT scans and end-stage cancer drugs we must be willing to forego for our future possible selves in order to create a more inclusively just health care system.

Nothing short of that Great Awakening and the resulting new health care covenant will have the force needed to overcome the special interests that will otherwise dominate legislative efforts aimed at health reform. Ethical sentiments divorced from the difficult and demanding work of democratic deliberation are just rhetorical ornaments happily appropriated by legislators. If we want...