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	James L. Holly, M.D.

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Your Life Your Health - Father's Day and Healthcare Policy: How Are They Related?

James L. Holly,M.D.

June 14, 2007

Your Life Your Health - The Examiner

This will be the second Father's Day I have spent since I joined the ranks of those who only have memories of their fathers. However, I realize how selfish this lamentation is as my wife is spending her 23rd Father's Day since the death of her father.

Yesterday, Sunday, June 10th, as I drove to Natchitoches to visit my mother, who is convalescing from hip and shoulder fractures, I thought about my parents and about reasons why we find life valuable and worthwhile. Family is one of the chief of those. I thought of my wife who was at home ill and I realized how totally lost I would be without her and how lost my mother must feel without her spouse of 64 years. By the way, I was so proud of this 90-year-old woman who walked 1,450 feet three times during my Sunday visit.

Strangely, I thought of something which in context seems odd. I thought of Burt Lancaster's largely fictional portrayal of Robert Stroud as the “Birdman of Alcatraz.” In one poignant scene during a riot, Lancaster responded to another prisoner who saw life as futile and worthless; Lancaster said, “Life is too precious not to try to hold on to it.” The contrast between these two characters, one who sees no value in life and the other who sees life as having ultimate value, set me to thinking about Father's Day and healthcare.

What is the connection? Among many other things, the meaning of father's day is an element of those things which have given purpose and direction to my life for sixty-three years. For healthcare efforts to be successful, those who seek care must find life to be valuable and worth the effort to preserve that life in order for them to make “healthy choices.”

In the recent presidential debates, I have heard a great deal of about universal, single payer, preventive, cost-effective healthcare. In the context of the value of life, I realized what is missing from this discussion. First, it is imperative that the United States acknowledge that healthcare is a right of citizenship and even residency in the United States and not a privilege of wealth. This is not such a radical idea but it seems radical because the practical implications of that idea have never been honestly addressed.

I find life to be valuable for a myriad of reasons and am therefore willing to make certain choices which contribute to my health - exercise, avoiding tobacco, not drinking alcohol in excess or even at all, eating fruit and vegetables and routinely avoiding fatty foods, etc., etc. But these choices are synergized with chance or blessings, depending upon your world view, of genetics, opportunity, resources and a social-support system, all of which contribute to the value of my life and thus the willingness to make “healthy choices.”

It is easy and it should be easy to affirm that healthcare ought to be a right; it is not so easy to design a delivery and a payment system which will support that idea effectively. Initially, it may seem that the solution is to “take all profit” out of healthcare and thus reduce the cost. But, will it? Here is the probable scenario. Currently, excellent healthcare providers work extremely long hours and often are rewarded for that work with income which “social engineers” look upon as fertile fields for reducing the cost of healthcare.

It will be easy to get Republicans - who traditionally have supported and promoted changes to the healthcare system which have put pressure on healthcare providers' compensation - and Democrats - who traditionally have yearned for a single-payer, national healthcare system - to vote for a system which makes healthcare providers employees of the government, or of a private healthcare system. This is guaranteed to save money and to pay for expanding healthcare to all of the people, we are assured. However, when physicians become employees healthcare they are unwilling to work 12-18 hours a day 5-7 days a week. Thus, we will have to increase the number of the healthcare workers and all of the savings from their reduced compensation will be absorbed because there are more of them.

However, this is not the most insurmountable problem which we face. The biggest problem comes from how and whether people value their lives and whether they are willing to make the choices to improve and/or to preserve their life. In a free society, we not only have to answer the easy question of whether access to healthcare is a right; we have to answer the not-so-easy question of whether society has the right to impose care upon those who do not want it!

Does society have the right to design a healthcare system and demand that everyone fit into it? If society is going to provide care for everyone, can society then demand that everyone make certain healthy choices? Can society require that those who don't make those healthy choices, face consequences either in their access to care and/or in the cost of that care?

In our spectator society, we have developed a system where people who are unwilling actively to make any changes or choices in their life in order to retain or regain their health, demand that society provide passive ways for them to escape the consequences of their wrong choices. For instance, those who are unwilling to discipline their appetite to lose weight, demand that insurance companies, i.e., society, pay for their lap band procedures and then for the complications of that procedure. The patient becomes a spectator while others work to preserve their heath without any effort on their part.

And, because they often feel helpless and hopeless while still receiving those passive treatments, these healthcare spectators often aggressively, stubbornly and wittingly continue the behaviors which brought them to their point of illness. If we are going to provide healthcare for everyone, we have to ask the question, “Can we afford to allow everyone actively to wreck their health and passively to receive expensive and recurring solutions to those problems without any effort to change their habits? Any healthcare system which is designed for success must include accountability and responsibility for all stakeholders: deliverers, payers, recipients, administrators, etc.

There are two ways in which healthcare cost are unmanageable. One, care is not sought until a crisis arises. This limits options and prevents less costly interventions. For instance, it is easier to treat the bladder infection than it is the sepsis and shock when the bladder infection is ignored. It is easier to give a flu shot than to treat the effects of a full-blown viral-induced collapse. In a system which will work, people cannot refuse preventive health and then demand carte blanche to receive treatment for the consequences of their wrong choices. The other is that the entire burden for success is put on the delivery system without any expectations upon the recipients. The transfer of responsibility for health from the patient to the provider is a not-so-subtle avoidance of responsibility and rejection of accountability. Any system which is designed without accounting for this will fail.

Do people have the right not to seek care until they have a crisis?
Does society have the right to demand certain behaviors of people?
Does society have the right to hold people accountable for their choices which injury their health?
If society has that right, where does it begin and where does it end?
How far can a free society go in imposing restrictions and demands upon free people?

These are hard questions and there are no easy answers but it is not possible to design a workable healthcare system which can be sustained without answers to these questions. Ultimately, however, it seems that the only way to design such a system is with the assumption that everyone finds life to be valuable and in Richard Stroud's terms, “precious.” Without hope - the expectation that change will be good and that effort will bring change which is good - and without resources to buy the right kinds of food, to avoid dangerous circumstances, etc. -- it is improbable that much will change.

In many places and in many ways, we have to decide if we want a free society, or a socially-engineered society. A free society will of necessity have a healthcare system which is not totally systematic. A socially-engineered society will of necessity impose upon people things which are judged good by society but which may not be judged as good by every individual.

So much of healthcare is wrapped up in beliefs and social mores. Some cultures within the United States find it impossible to deal with end-of-life situations except with the declaration, “We want everything done.” In a system designed with no accountability and no responsibility, it is easy to say “I want it all,” because there are no consequences for those making these decisions. On the other hand, we do not want a system designed whereby arbitrary thresholds are determined such that if you are this age, or have that condition, there is no care available to you. Where is the balance?

We cannot afford to give everyone, everything they want. When healthcare expenditures provide no quality of life, should society guarantee the availability of those expenditures? And, whose definition of quality of life is going to be used and who is going to determine the presence or absence of that quality of life? “All you can eat” buffets often note that if you do not eat all that is on your plate, you can be changed more. That is a form of accountability. The idea is, “Just because it is available does not mean that you should take it.”

In my father's final illness, it would have been possible to delay his death almost indefinitely, but his life as he knew and as he loved it, was over before his body ceased to function. To artificially prolong that life would have been cruel. It was because of our judgment of the value of his life that we chose not to prolong the biological functions of his body. Our judgment of the value of our father's life caused us to make choices which preserved his life and ultimately that value caused us to make choices which allowed his life to end.

The value which each person places on his/her life; the choices each person makes for her/his life; the investment which society makes in the life of each of its citizens and/or residents; accountability and responsibility; freedom, these are all elements of the design of a healthcare system which treasures the life of each person.

It is soon to be Father's day. If you still have your father; treasure him. If you still have your health, treasure it. If you have neither, encourage those that do to value both and to make choices which reflect that value. Remember your father and celebrate his life. Life is precious, even after it is gone. And, don't every forget, it is your life and it is your health.

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