The banality of health care reform

Insurance…will pay for the amputation of a limb to treat diabetes-related gangrene, but not for the conscientious follow-through that can lessen the probability of needing such costly and tragic remediation. This is not the fault of physicians or insurers. The fault is in the misapplication of a business model that was designed for the practice of acute medicine long ago.

Christensen, The Innovator’s Prescription, p. 164

I’m almost finished with Christensen’s The Innovator’s Prescription, and I still can’t shake the feeling I had 75 pages into the book: although I agree with his assessment of health care in the technical sense, I feel that there’s a moral/ethical dimension to the health care problem that he ignores that simply can’t be ignored.

The quote above is a prime example of what bothers me about Christensen’s analysis, even while I’m nodding my head to 95% of what he’s all about. He admits that the way our health care system handles the complications arising from diabetes is “tragic”; but at the same time he absents physicians and insurers from blame, pointing the finger instead at “the misapplication of a business model that was designed for the practice of acute medicine a long time ago.”

The use of the passive voice here is telling: who exactly is misapplying the business model if not providers? And who is encouraging this misapplication if not insurers?

Even in terms of the origination of the business model, Christensen seems to avoid pointing the finger: who’s the subject of his “was designed…long ago”?

We might chalk this passivity up to a desire to stay out of the fray, to avoid muckraking, and to let his analysis of the problem stand on its own two feet regardless of the moral or ethical judgments.

But can we be okay with this value-neutral stance given what’s at stake in health care? After all, we’re not talking about whether consumers get a better widget for less money, but whether someone gets their leg amputated or dies from complications that were easily avoidable if not for the mechanics of our broken health care system.

In the end, I’m led to draw a comparison with another difficult moral/ethical situation the U.S. faced: the Holocaust—although I’m aware that this parallel has been overused and can be somewhat of a cop-out: simply by invoking it, you can absolve yourself from critical thinking because the evil is so powerful, it can eclipse the need for rational justification…

But keeping this in mind, if we consider Hanna Arendt’s take on the Nuremberg trials in her groundbreaking essay The Banality of Evil, there are many similarities between how she views the mechanics of Nazi Germany and Christensen’s passive view of how the U.S. health care industry treats diabetes-related complications.

Arendt’s main insight was that the average person, Nazi or not, is not inherently evil. If presented with obviously evil tasks (like shooting prisoners point blank in front of a ditch), they would be unable to perform them over the long haul. But if these same people were given tasks that mimicked everyday tasks (drive a truck, guard barracks, schedule trains, carry bodies), they could perform them with few objections for years at a time, even if they resulted in the death of millions of people.

“I just put the people in the trucks.”

“I just help the people out of the trucks.”

“I just lead the people into the showers.”

“I just carry the bodies out of the showers.”

“I just bury the bodies in the graves.”

The mechanism in play here is between the cracks—no single person is responsible for the death of prisoners, so everyone can justify their participation because they are not individually responsible for the horror that results from the operation of all the steps.

For me, Christensen’s understanding of health care too easily absents the main players from responsibility for the outcomes we currently experience. If those suffering from diabetes are incented to let their disease progress until they require amputation, that responsibility falls on someone…and it’s not the diabetes patient. We are each responsible for our behavior, of course, but when institutions could easily help consumers avoid tragic consequences, I think they have a responsibility to do so.

In the end, I’m beginning to see that, although the answer to the problems of health care in the U.S. has a technical, academic dimension, it can’t ignore the moral/ethical dimension. What do you all out there think? Love to get the conversation started…

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2 Responses

  1. Socialists make this claim for every single industry they want to nationalize. This applies to:

    Agriculture: We need collectivized farms because private businesses do not follow the right model.

    Industry: We need to collectivize factories…

    Movies: We need to… you guessed it!

    Its always the same f***ing thing and the people are getting tired of it.

  2. What makes health care different from other forms of “industries” is te level of uncertainty and asymetrical information. The market uses price as a way of conveying information. But when when we engage doctors, we expect that doctors will have the correct information – its a life and death matter. We can’t simply return a doct’rs information like shoes.

    Further, there is the issue of time. People get sick in time, and moments matter. Individuals can deliberate years before buying a car; they may not when getting cancer treatment.

    Your article echoes Gawande’s thesis that doctors would benefit from being paid for outcomes rather than per procedure.

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