Ethics, Pain Care, and Obama’s Policy Intentions
As leaders in Congress seek consensus on how we might address and rectify problems in our nation’s health care system by year’s end, we are reminded of the need for ethically-informed pain care legislation. President Obama himself recognizes that it is a moral imperative—and not simply a practical necessity—for our elected officials to provide better care for those who suffer in “…mind and body.”1 As such, it implicitly recalls the difficulties of pain medicine in dealing with pain as an event of body and the brain-mind, as well as the subjectivity of its experience and the objective personal and socio-economic realties it incurs. Thus, for Mr. Obama and those in various tiers of politics who direct their focus to health care reform, the issue is not simply why, but what form such change(s) will assume and how these will be developed, implemented and ultimately affect the social good.
Something(s) Old, Something(s) New…
While few would doubt that our legislators have an ethical obligation to guard, preserve and attend to the health of its citizens, we suggest that it is important to view this obligation more broadly so as to encompass a meaningful definition of health and the scope of responsible pain care that arises from such a construct. This is not a new or novel task. In 350 BCE, Aristotle conceptualized true health and well-being as a function of moderation and self-restraint when he observed that it is “…the nature of (natural) things to be destroyed by defect and excess.”2 Thus, a healthy person, and (by extension) a healthy population, avoids extremes in the mundane as well as the more critical choices of daily life. Aristotle’s point was that health—of both the person and the polis—were related to, reflective of, and dependent upon temperance, wisdom, and responsibility. In an age of ever-increasing choices and call(s) for more personalized care, we must ask how policies can be created that accommodate some level of our libertarian values and, at the same time, enable the execution of expert skill and knowledge in ways that are morally sound yet economically viable. At first blush, the task at hand seems Gordian—untangling one thread of the knot imparts tensions to others.
To look ahead, we may need to reflect upon the wisdom in the classical view and Aristotle’s claim that “…legislators make the citizens good by forming habits in them, and this is the wish of every legislator, and those who do not effect it miss their mark” is just as relevant today as it was centuries ago.3 It speaks to the reciprocity between the sciences, medicine, humanities (i.e., philosophy, ethics, sociology), economics and politics to inform the public and, at the same time, be informed by the public in making those decisions that affect and sustain the social value of healthcare. Hence, as Aristotle recognized, a “healthy” citizenry makes for a stronger republic. But toward such ends, we must also recognize the responsibilities of the “strong” (viz. those in power, whether medical, economic, and/or political) to mitigate the plight of the weak (viz. those who are marginalized and vulnerable by the condition of disease, illness and suffering). In light of this, while we can state that elected officials have a duty to promote and sustain the well-being of their constituencies, they cannot force it, but can—and we argue, should—in Aristotle’s words, “effect” it.
We believe that President Obama would not disagree with Aristotle. In his address to the American Medical Association on July 15, 2009, the President expressed a concern that Washington must “…invest more in preventive care so we can avoid illness and disease in the first place” and “starts with each of us taking more responsibility for our health and for the health of our children.”4 In the opinion of the President, the ills of our health care system are due, to some extent, upon the unhealthy habits of our citizenry. This is not to point an accusative finger at the public, nor is it meant to deny the obligations of the economic and political infrastructure to provide ways and means for safe, available and affordable healthcare. However, it is meant to draw attention to the fact that as our potential choices for healthcare provision multiply (e.g., new and advanced technologies, drugs, and medical services), the mere presence of such available options does not negate the more primary responsibilities for prevention and prudent decision-making in accessing those means that are sought and utilized in medicine. Simply, as choices increase, the obligation to understand the relative value of various new tools and methods increases concomitantly, as do the needs for economic and policy support to allow responsible use, as required.
On Responsible Choice
Even though the President exerts considerable influence over the shape of America’s health care overhaul, it is Congress that must codify such an ethic into law. As it stands today, House Resolution 3200, known as “America’s Affordable Health Choices Act of 2009” mandates that $2.4 billion be spent on preventative measures in 2010 alone (this would rise to $3.5 billion by 2014). In actuality, this would not only fund biomedical research and direct clinical applications of public health, but would also support more indirect aspects of health, such as parks, bike trails, etc. But despite this somewhat ‘holistic’ orientation to health, all wellness plans through which individuals might be able to lower insurance premiums by undergoing medical screenings, have been stripped from the bill. To be sure, this approach has been criticized as being too obtuse and, even if restricted to more seemingly clinical domains, HR 3200 falls short of incentivizing moderation in health care options and choices and supporting such prudence through economic allocation. Regardless of political affiliation, these omissions should concern all members of the medical community.
It seems that this fiscal plan might require further deliberation so as to better evaluate where and how the needs of the public and the medical community intersect, and how a more finely-grained economic package might be developed that would (1) sustain research in disease prevention, treatment and management, (2) translate these research efforts into clinically-relevant resources, (3) make available and justly distribute both low- and high-tech resources, and (4) prompt fiscal programs that support, allow, and reinforce responsible choice (of such resources) in both preventive and treatment paradigms.