Contribution to the conference “From Sick Care to Healthcare in the Age of Learning”, Stockholm Sep 7-8, 2002.

Insatiable Demand and Infinite Supply. The Moral Limits to Healthcare.

I am a writer and a journalist, not a physician or a health care professional or an academic specialist in the field. I have come to the issue from some basic experiences, some basic research and some basic reflections.
Reflections on a very basic question in human life and history, namely, why do we do the things we do? What are the forces that motivate us?
Is the motive for giving care to the sick the same as the motive for, let’s say, producing steel or making bread (to use Adam Smith’s classical example of self-interest-driven markets)?
Or rather, can all activities in human society be based on one single model of human action? One single idea of why we do the things we do?
All this, work that will hopefully emanate in a book.
The reason I have begun to ponder this issue, is the emerging belief that a whole range of human activities that previously were thought to be motivated by, let’s say, love or duty or a sense of obligation, i.e. motives that are essentially social and self-transcending in character, can now be motivated by self-interest and profit, i.e. motives that are essentially individualistic and self-contained in character.
The activities I am talking about are for example education of the young, care for the sick and disabled and care for the elderly.
In all these fields we have witnessed attempts to replace duty-based motives with, what I call, profit-based motives. Social trust with economic bench-marking and auditing.
Even not-for-profit institutions have increasingly had to accommodate to the logic of market forces, basing their activities less on social trust and more on economic controls. Bradford Gray calls it the “objectification of Medical Care” transforming health care to commercial products that can be objects of economic transactions, controls and negotiations:
“Economic motivations have come to the fore … conditions that might moderate the influence of these motivations have been weakened.” (Bradford H Gray: The Profit Motive and Patient Care. The Changing Accountability of Doctors and Hospitals).
In Sweden this change of motives is taking place within a framework of public financing, creating increased tensions between public considerations and individual incentives. The health care system can simply not provide what an aggressively growing market of health care products prompts it to provide.
This is leading to increasing gaps between rhetoric and practice and to the development of a private insurance system alongside the public one.
In the US the change is taking place within a system of mainly private financing, creating increasing demands on the part of insurance companies and third-party health care managers for quantification and specification of cures and treatments in order to make them amenable to market-based controls. Efficiency in care measured in terms of input and output. Input being economic resources, output being economically measurable states of health.
We can see this gap in the fact that the largest for-profit based hospital chain in the US, HCA Inc, running 181 hospitals and 80 outpatient surgery centers in 23 states, recently reported a 25 % increase in its second-quarter profit, “driven by an increase in admissions and higher reimbursements from health insurers”. (WSJ 25.7.02) While at the same time it was reported (LA Times, 31.7.02) that the number of Americans without health insurance is increasing with 2 million people per year and that many Americans who previously could afford a private health insurance no longer can, because of raised premiums and tightened conditions for entering the insurance system.
The same trend by the way in Sweden, where premiums of private insurance policies are continuously raised as ever more human conditions of discomfort and suffering are demanding to be defined, included and covered.
I will argue that the shift of motives – from social duty to market-based profit – has created a dilemma that cannot be handled within the framework of individual choice and profit-based health-care systems.

The Dilemma

The rapid development of an increasingly profit-based healthcare industry offering ever new cures and treatments for ever new human illnesses has created the potential for a healthcare-market characterized by ”infinite supply”. There are simply no clear technical or biological limits to what cures and treatments and bodily enhancements that can be offered at some price.
This race towards “infinite supply” is interacting with an increasingly “insatiable demand” for healthcare and healthcare-products. The marketing of new products for avoiding disease, eliminate suffering, enhance genetic properties, replace body parts and prolong biological life, will at each and every point create new needs and demands.
The development of a market where ever more money can buy ever more health and care, will most likely lead to the fragmentation and dissolution of publicly financed healthcare-systems.
This development cannot be regulated and controlled by reforms within the healthcare system itself since the problems are not of an organizational or informational character. The development of patient-managed systems will only serve to drive the “insatiability” of the demand. The development of profit-driven healthcare systems will only serve to stimulate the infinite supply.
Any discussion of what healthcare can and should be offered to whom, I argue, must be based on a moral vision of human life, a vision that has place for disease, disability, defeat, aging and death.

The infinite supply

What do I mean by “infinite supply”? I mean a supply of products that carry the promise of individual liberation from disease, pain, ugliness, aging and – eventually – from physical death. For every conceivable (and non-conceivable) human or spiritual defect we expect to find an existing or soon-to-exist health-care product. Reports about promising cures and treatments are regular top stories in the media. As well as reports about diseases and illnesses for which there soon will be new cures and treatments. This is of course a promise without end, since there will always be an infinite number of steps and stages along the road, which of course in itself has no end.
Furthermore, most new drugs registered add little or nothing to the effect of previous ones, making the steps toward eternal bliss infinitely small, sometimes in the wrong direction (Rosén, Beermann: “Rating innovative therapeutic benefits of medicines licensed in Sweden 1987-1997”, International Journal of Pharmaceutical Medicine, 1999, 13: 123-126).
Drugs not only cure but also tend to create new, iatrogenic, diseases. (From Greek iatros physician, and English –genic, health damage induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures). 180 000 people reportedly die in the US each year as a result of iatrogenic injury.
And still there seem to exist a large enough number individuals (a promising growing market, that is) prepared to pay for those infinitely small additions to their well-being, not to mention the larger offers at hand of limitless remaking and rejuvenation.
Since the health products and services being marketed are still being conflated with the non-marketable goods of love and care and human obligation, their supply will come to be regarded as a human right, and their non-supply as a social deficiency to be met one way or the other.
Increasingly part of the popular culture, these potential products are now peddled everywhere.

The insatiable Demand

We all know of course that the Promise is untenable. The supply of products from the health care industry might be limitless, but the goods these products can deliver are limited and will remain so, since what we ultimately expect, unconditioned human care, perhaps also human love, is not a product.
Neither are disease, illness and human discomfort medical problems only. We can live well with a diagnosed disease, and we can feel miserable without any such disease to blame.
Nevertheless a growing pressure on the demand for health care is being created by the latter category, since individual hope for liberation from ailing and suffering has become increasingly linked to the diagnos of a disease which can be treated and cured by the products and services of the health-care industry.
As Ivan Illich provocatively argued in his well-known essay “Disabling Professions”:
“ Ever more ‘ills’ become ‘illnesses’ to be treated by doctors, and people lost their will and ability to cope with indisposition, or even with discomfort.” Or more dramatically put (Illich): “Life is paralyzed in permanent intensive care”.
Some years ago, when I edited the monthly magazine Moderna Tider, we published a piece by Illich, with the cover showing Jesus taken from the cross to an intense care unit and the text: "Life at any cost?"
There would of course not have remained much of Christianity if that cover had depicted its founding myth.
What did we want to achieve with that issue?
We wanted to highlight and discuss the inability of a individually need-driven society to set limits to what health care can and should be about. Not to mention its inability to set and accept the limits of individual life and existence. These were as you probably all know the problems that lay at the heart of Ivan Illich’s radical critique of the professionalized society in general and the professionalized healthcare industry in particular.
What he argued for was the need of what I would define as moral limits to health care. Limits derived from a view of life and death, health and disease, well-being and suffering, as inherent tensions in human existence.
Eventually leading us to finding out what we do not want from the health care industry.
“ Self-chosen joyful austerity”, as he himself choose to put it.
Even if we do not happen to share the specifically austere ethos of Illich, I believe we must concede that his discussion is even more relevant today as it was when he formulated it some 30 years ago.
There is no way in which the present dynamics created by a system of individual choice on a market of infinite supply will be able to set those limits in a way that will be consistent with the social and moral obligations between individuals and generations on which these activities are ultimately based.
We don’t provide care because we may profit from it but because we have to.
We have to because these are social activities made necessary by human beings inter-generational dependence on each other.
We have to do it, not because of our immediate survival as a biological creature but because of our long-term survival as a social species.
The one motive does not automatically entail the other. The first motive comes to us naturally, instinctively, if you so wish. This is the animal in us. The other motive is culturally produced and socially learned. This is the specifically human in us.
This distinction between different motivating forces has always been seen and recognized and incorporated in every narrative of the human condition.
That is why we have inherited the oath of Hippocrates and not his business plan.
This distinction – between profit and duty – as diverse and at times incompatible motivating principles, I argue, must be recognized and dealt with if the long-term social obligations of any health care system can be balanced off against the immediate satisfaction of individual needs.
These two diverse principles actually do give rise to two diverse moral syndroms, both necessary but not necessarily compatible, as argued by among others Jane Jacobs, in her fascinating book Systems of Survival.
This means that the issue on how to organize a healthcare system able to balance infinite supply with insatiable demand, to a significant extent must be a moral one.

The “learning organization”, patient-based systems

How does that square with the management approach to health care? With new ideas for a more patient-based health care system promoted by many, giving the individual more say and more control over her health care consumption, (Levin & Normann), or creating a new “learning” organization (Maccoby).
These systemic approaches still beg the question, what will be the motivating forces at play in these systems. Duty (trust & commitment) or Profit (control & competition). Can long-term relationships of trust be developed in systems driven by short-term control and competition?
Various patient-managed systems are now mainly promoted by the for-profit health care industry itself in order to create direct commercial links between producer and consumer.
• In ads on American TV patients are told to tell their doctors about new subscriptions drugs.
• In public policy ads by Pfizer we are told that “Medical professionals must help patients understand that in return for greater power, control and choice over the services and treatments they receive, they must bear greater responsibility for their own care.”
“Let’s start asking not just what health services can do for patients, but what patients can do for themselves.”
I do believe that this approach is ignoring the inherent imbalance of power between the sick and healthy, the needy and the provider, not to mention the run-away imbalance between insatiable demand and infinite supply.
Replacing “professional dominance over their life”, to quote Illich, with the even more powerful dominance of the professional and the commercial.
Health Care is at its core not an issue of rational or enlightened choice. It is an issue of moral obligation, stemming from collective and long-term social needs.
It therefore needs a human vision not only of individual health but also of individual suffering, failure, sacrifice and defeat.
In contrast to recent ads in Swedish newspapers by the regional health care authority of Stockholm for a new health-care guarantee, basically conveying the message that within three months you will be cured from your ills and can go on with life where you left it.
Sometime you can. Sometimes you can’t. Not to mention the limits of what a guarantee of this sort is worth.
There are limits to health care that cannot be organizational in character but must be moral.

The Moral Limits to Health Care

Ivan Illich understood this long ago.
Any concept of health and cure needs a concept of suffering and defeat. Every vision of limitless health-care needs a vision of the limits of human life. Illich set his hope to
“Thousands of individuals ands groups challenging professional dominance over themselves and the socio-technical conditions in which they live”
Individuals and groups that would clarify to themselves and others what in common they do not want.
He too advocated a kind of learning organization, but among the most important things to be learnt was that health is not everything in life and that health-care cannot cure us from ills that are inherent in human existence.
That what we need to learn is not only to formulate our needs but also to formulate their limits.
The latter requires not only a learning organization or a morally motivated management but a society based on a moral narrative of life, health, suffering and death.
Or as Illich once put it:
“ A general theory that places [individual] freedom within publicly chosen limits above claims from ever more costly packages of ‘rights’”.
I think Illich asked the right question.
I also think we have not yet begun to ponder the right answers.