Healthcare Professionals for Healthcare Reform

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Making Policy that Makes Sense

A new administration has been inaugurated into the corridors of power.  A new cadre of public health elite has been, or soon will be, installed.  So perhaps there is a new opportunity to embrace the rationality and first principles too long absent from public health policy.

            The meaning of rationality is perhaps self evident.  In essence, it means decisions and actions make sense.  They are consistent, and cogent, and don’t contradict one another.  If, for instance, evidence shows that sex education and the availability of barrier contraception can reduce unintended pregnancy and sexually transmitted infections without encouraging sexual activity and these are socially desirable- then policies that advance these objectives are rational.  Policies that impede them are, arguably, not.

            The notion of first principles is perhaps less immediately transparent, although equally fundamental.  It means that a series of related decisions, actions, or policies should all derive from a common guiding principle, or principles- namely, the first principle.  So, for example, the principle that we should not drive after drinking wine, or beer, or vodka, or gin- all relate to the first principle that we should not drive after drinking alcohol.  In this rare instance, we may be thankful we have extant policies of reasonable cogency.

            With definitions dispatched, I would like to make the case that we are at best disrespectful, at worst altogether dismissive of first principles in much of our public health policy- and for that matter, much of our collective decision making.  Examples from both clinical medicine and public policy abound.

            As anyone else who has passed through the rites of medical education can attest, there is a wrestling match in every emergency department of every teaching hospital every day over the fate of potential admittees to the hospital.  The emergency resident, responsible for immediate treatment only, is eager to admit every patient that cannot readily be sent home, and thus unclutter the perennially cluttered ER.  The admitting resident, however, who assumes (or delegates) responsibility for the on-going care of admitted patients is not only eager to deny such admissions, but actually earns kudos from fellow residents for being ‘a wall.’  There is no higher praise for an admitting resident than universal acclamation of his or her wall-ish-ness.

            Where, you might quite reasonably ask, in all of this are the clearly elucidated, carefully vetted, and universally accepted criteria for hospital admission versus the alternatives?  They don’t exist- and are certainly not taught.  Perhaps it’s because we all actually enjoy those wrestling matches.  But I suspect it’s the fact that we often grapple with specific decisions while ignoring the underlying first principles on which they should be based.

            The data we have suggest there is much public opposition to the use of medical marijuana.  Superficially, this is quite sensible; why would anyone sanction the use of an illegal drug for purposes medical, or otherwise?  But then again…there is cocaine in every emergency department in the country (we use it to treat severe nosebleeds).  There are narcotics, some of which are close cousins to heroin but even more potent. 

            Where, then, in this debate is any semblance of rationality or a first principle?  Do we ban all potentially dangerous drugs?  Clearly not.  All drugs that are illicit for general use?  Not that either.  Do we, then, defer all such decisions to trained medical professionals, and trust that if they can decide when to administer cocaine, they should be able to decide when to administer cannabis?  Apparently not that either. 

            On the vexing topic of physician-assisted dying, first principles are simply mowed down on a slippery slope of inconsistencies.  Our policies- and, I suspect, our personal predispositions- favor the option of palliative care, even if the pursuit of palliation at times accelerates death.  But not if it accelerates it enough for it to be obvious that there is an actual cause and effect relationship.  This all boils down to timeline: we can do what kills as it comforts if it kills too slowly to make the link obvious.  If it kills a bit faster, it’s taboo.  If this makes sense to anyone, I would welcome their attempt to explain it to me.

            Perhaps the granddaddy of all inconsistencies is our approach to the whole topic of health care.  Is it a right, or a privilege?  Rather than beat that topic into its submission of a first principle, we continue to debate all of the specific ramifications of failure to establish some general rules.

            We all agree, I trust, that the new arrival in an emergency department with a life threatening gunshot wound gets treated without first ascertaining insurance status.  This suggests that at least some extremes of health care are a right.  What if the wound threatens limb, but not life?  Do rights extend from the person to the appendage?  From the appendage to a digit?  And if digits have a right to health care, is it only for bullet wounds, or does it extend to the more grisly of paper cuts?  A quagmire, to be sure, but one we cannot hope to escape without the consistent guidance of a first principle decision.

            Connecting this simple sequence of clinical dots impels us- and more irresistibly than bombastic posturing could- to the concession that some health care is a de facto right, some a privilege: bullet wounds to one side of the line, paper cuts to the other.  That, in turn, implies the inescapable providence of health care rationing.  By refusing to acknowledge its providence, we don’t escape it- we simply acquiesce to it irrationally.  Establishing first principles would allow for far more rational rationing of health care than currently prevails.

I am not advocating for any particular policy.  I am advocating for an approach to generating policy, and for that matter, personal decisions.  I believe progress of all varieties is forestalled by our willingness to assert positions not held accountable to the meanest standards of consistency, and rationality.  Our tendency, if you will, to shoot first, and debate gun control after.

There are innumerable hopes and aspirations attendant upon the current, historical transition in power.  There are, no doubt, trepidations and anxieties in certain quarters as well.  Into this volatile brew, I cast my own temerarious hope: perhaps we might make collective decisions- and public health policies- that actually make sense.




Dr. David L. Katz;


January 24, 2009 - Posted by | Uncategorized

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