Health Care: Rights And Obligations

Dean Kagan was not my Harvard Law School professor of constitutional law, but Professor Arthur Sutherland, a gentle scholar with a penetrating mind (and wit) was. He taught us that rights are closely tied to obligations. Although health care issues may seem too mundane to be linked to Harvard legal principles, Sutherland's message remains relevant: health care rights and obligations are inextricably linked.

In 2008, when I started this blog, I discussed the franchise that health care professionals obtain when they receive their licenses, granting them their rights to practice, and noted that their rights were accompanied by serious professional obligations to provide services in the public interest which those licenses were granted to serve. For physicians, it means the obligation to provide care for desperately ill patients who may not be able to afford the health care provider's "usual and customary fee." For licensed (franchised) hospitals, whether for-profit or not-for-profit, it means taking care of the needs of those who would become seriously impaired, suffer unnecessary pain, or die without the hospital services the institution is licensed to provide. For licensed (franchised) insurance companies, it means considering issues above and beyond profit when underwriting and providing insurance benefits. For patients who proclaim their rights to health care, it means taking those personal measures which promote health rather than (i.e., alcohol, tobacco and dangerous drugs as well-as high-risk behaviors) demand that society take the responsibility to correct the damage they have done to themselves. It may mean understanding that the demands which an individual makes on the health care system may be unrealistic, unnecessary and economically impossible and, if met, may result in the system being unable to provide basic care to others.

Each of us will require health care. When we (or our surrogates) make demands upon the our health system, we should understand the system's capacity, it's obligations and our own. Health care does not represent a bottomless trough at which we can all line up to get our fill. Nor is it an ever-growing source of revenue to its franchisees.

What are your health care rights? And what are your obligations?

The Past, Remembered

Today's Saratoga California Rotary Art show, at a nearby public community college was wonderful. All of the usual arts were represented and my wife and I enjoyed our walk through the displays on a warm sunny Spring day. Until we smelled a really foul cigar smoked by a chubby late-middle aged man in a straw hat. We checked with the art show staff, where others were making the same complaint about the same person, and were told that there were many signs indicating that smoking was prohibited anywhere on the public campus. When we later ran into this smoker again and told him what we had learned he waved at us, indicating that we were the ones who should leave.

As one who formerly smoked, I understood the cigar smoker's addiction (and the rudeness which he used to ward off any threats to his denial of addiction). I also remembered seeing acutely sick patients of all ages in hospital emergency rooms, brought there by the toxic effects of alcohol and tobacco. Tobacco and alcohol are major factors in the cost of United States health care and we will not succeed in "health care reform" until we reign-in the use of these dangerous drugs.

A number of years ago  my wife and I attended a conference on the USSR presented by a noted Harvard professor who told us that the USSR was dependent on its revenue from taxing alcohol (primarily Vodka) for many of its national expenditures, including defense.  He should have gone further to indicate that America and its individual states also have an ambivalent approach to smoking and drinking because the nation and its political subdivisions derive substantial revenues from alcohol and tobacco.

If we want health reform, and individual health improvement, we need to resolve our national ambivalence and convince Americans to stop smoking, stop using "chewing" or  "mouth" tobacco, and stop drinking to excess.  If we divert money from our unsuccessful narcotics interdiction programs to high-power campaigns to deglamorize tobacco , alcohol and other controlled substances, maybe we could really cut health care costs and improve results.

That cigar, today, smelled awful.

European Health Inequalities: Socioeconomic or Cultural?

The New England Journal of Medicine article by Mackbach, Stirbu et al, "Socioeconomic Inequalities in Health in 22 European Countries," (N Engl J Med 358:23, June 5, 2008) states, as a summary conclusion, "We observed variation across Europe in the magnitude of inequalities in health associated with socioeconomic status. These inequalities might be reduced by improving educational opportunities, income distribution, health-related behavior or access to health care." (p. 2468). This appears to more of a political statement or agenda than public health policy. It also focuses on issues which are easier to analyze and deal with than the hard one: "culture."

In the editorial section of the same issue of the New England Journal of Medicine, Berkman and Epstein (p. 2509), look at Mackbach's article and note that: (i) the results in the 16 country mortality data show higher death rates for socioeconomically disadvantage people; (ii) the size of the risks varies across countries, and that " . . .the proportion of excess deaths related to diseases that are potentially amenable to medical intervention was strikingly low . . ." for the socioeconomically disadvantaged.

Berkman and Epstein (p. 2510) comment that, " . . . . although national health coverage is important for many reasons, we should not count on it to reduce more than a small part of the socioeconomic, racial and ethnic disparities and improve the health of the population."

A politically sensitive, and potentially more rewarding study, would focus on the health characteristics of identifiable cultures and subcultures. What are the cultural characteristics of socioeconomically disadvantaged persons who place a high value on the practice of a healthy life style (diet, alcohol, tobacco, societal value of females, maternal and child health, health education, physical activity) and how do their cultures vary from others which experience higher member illness and mortality? While it may be relatively comforting to identify socioeconomic disadvantage, and write a check to remedy this issue, without identifying and modifying cultural characteristics, no health benefit will accrue. (Those who have treated alcoholism know that alcoholism has cultural attributes which may help to predict treatment success.) While it may be politically easier and less threatening to talk about matters of economics, those who conduct health research should move to study scientific issues and not be constrained by political considerations.