The Second Fifty Years Promoting Health and Preventing Disability (1992) / Chapter Skim
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Appendix A: Can Philosophy Cure What Ails the Medical Model?
Appendix A: Can Philosophy Cure What Ails the Medical Model?
Pages 291-310
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From page 291... ...
At least 30 million Americans have no health insurance. Tens of millions of Americans, knowing they lack adequate medical insurance, dread the prospect of prolonged hospitalization or extended stay in a nursing home.
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From page 292... ...
And the evolution of health care in the United States during the past few decades would, at least at first glance, seem to provide strong support for the position that controlling the cost of success requires the drawing of clear lines of ineligibility concerning access to health care somewhere in the second half of the human lifespan. Despite the glaring inadequacies in existing public and private insurance programs, and despite consistent public opinion poll findings that Americans are willing to pay more to remedy gaps in their health insurance coverage, Americans have shown little inclination to reach into their wallets when actually asked to ante up funds in the form of taxes of one sort or another.
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From page 293... ...
New technologies, both diagnostic and therapeutic, continue to pour out of the medical research cornucopia at a rapid rate.~37 Success in the discovery and dissemination of acute care meclical technology, progress funded in large measure by public monies administered through the National Institutes of Health since the end of the World War II, has brought in its wake all manner of burdensome fiscal consequences. Health policymakers in the United States must struggle to solve an ironic problem: how to ensure equitable, affordable access to the fruits of the many already or soon to be achieved successes that have resulted from the massive public investment in biomedical research.
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From page 294... ...
Perhaps not, if those responsible for planning health policy are willing to critically examine the philosophical premises that generate this apparently intractable dilemma: how to pay for the growing demand for more acute care medical technology when those who might benefit from this care do not want to pay for it.
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From page 295... ...
Changes in health habits and advances in the treatment of serious injury and illness mean that the demand for health care services is likely to increase for the foreseeable future. One in nine Americans in 1980 was over the age of 65.
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From page 296... ...
Some argue that we ought to focus more of our shrinking health care clolIar on children and the young as the most prudent way to utilize scarce funds.~5 32 Others argue that we need to place much more of an emphasis within the provision of health care on the prevention of disease, injury, and disability and far less on the treatment of acute medical problems.~9 Still others maintain that what is needled is a demedicaTization of health care problems in favor of more "social" approaches to the difficulties that face those who are impaired or ill.~6 4i The volume of debate about where the emphasis should lie in setting the aims and goals of health care has increased in direct proportion to the perception that rationing is and will continue to be the only plausible response to the high costs of biomedical success. What, it is reasonable to ask, can philosophical or ethical analysis possibly contribute to this bubbling maelstrom of health policy debate?
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From page 297... ...
Progress in the treatment of acute disease and success in afforc3ing longer lives to more Americans open the door to key philosophical questions about the response, both in terms of health care and public policy, that is appropriate in the face of a likely rise in the incidence of chronic illness, disability, and impairment.20 The investment of public dollars both directly and indirectly in the health care system in the decades since World War II surely ought to give legitimacy to calls for public debate about the best public policy response to the crisis of cost currently besetting our health care system. Philosophizing about the goals appropriate to health care is not so much a luxury as a necessity forced on us by our society's success in preventing or treating a wide range of what were once lethal diseases such as polio, smallpox, tuberculosis, meningitis, diphtheria, typhoid, pneumonia, renal failure, and traumatic brain injuries.
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From page 298... ...
Nevertheless, although combating disease and injury surely occupy center stage among the universally acknowledged aims of health care, there are other goals that may be served as well. For example, are those in health care fields responsible for promoting or preserving health?
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From page 299... ...
Even if one presumes that it is clear what health care professionals ought to do to fight illness and repair injury, what does it mean to say that those who provide health care ought to preserve or promote health? Not only is the link tenuous between health and the various interventions that health care providers offer28 {although only slightly less so in many cases than the links between health care interventions and the repair of illness and injury)
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From page 300... ...
THE DEFINITION OF DISEASE AND IMPAIRMENT: NORMATIVISM VERSUS NONNORMATIVISM The stakes involving definition of disease are, as many commentators have noted, quite high.2229 To label a state or condition a disease is to permit intervention by medical personnel, to grant access to various forms of social benefits, to confer a degree of exculpation from social roles and moral expectations, and to provide a framework for prophylactic, ameliorative, curative, and rehabilitative strategies. This fact has hardly been lost on members of certain groups whose physical condition or behavioral propensities leave them hovering near the borders of disease.
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From page 301... ...
The recognition that values play determinative roles in the classification of states and behaviors as diseases indicates that the locus of intervention in responding to or coping with disease can be quite broad, including social, economic, and even moral interventions as well as pharmacological, nursing, or surgical responses. Normativists see the determination of disease or impairment as subject to the analysis of both professionals and individuals because the values that determine well-being, unhappiness, or handicap are in the eye of the beholder and the professional.
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From page 302... ...
Other nonnormativists believe that, although value judgments may enter into the definition of disease, they need not do so when a sufficient understanding of the functional design of particular attributes of the human mind and body is available.36 Nonnormativism, if valid, also has direct and important repercussions for health policy and health planning. The scope and range of health care would be limited to those aspects of human life about which sufficient knowledge exists concerning the functions of the human body or mind to form a baseline for the assessment of disease.
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From page 303... ...
The assumption of decision-making authority by medical professionals is directly linked to the presumption that doctors can objectively assess dysfunction and disorder and then act to restore proper functioning, whether it be mental or physical. Although critics of the medical model sometimes chafe at the paternalism that is an omnipresent aspect of institutionally based health care, they fad]
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From page 304... ...
For if values are omnipresent in the diagnoses, treatments, and outcome evaluations that health care providers undertake, it would seem that the claims mace by medicine, nursing, public health, pharmacy, and other health professions of being scientific might collapse. Objectivity of the sort required by the norms and methods of science would not be possible in the domain of health care.
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From page 305... ...
There are many reasons to suspect that they do not. The medical system of the United States is strongly oriented toward acute medical care with the goals of saving life and extending life.
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From page 306... ...
Just as important, when medicine is not faced with the challenge of extending or preserving life but instead must confront the reality of chronic illness or impairment, there is a crucial need for the health care system to orient itself toward a goal other than that of extending life because there is no threat to life inherent in many chronic ailments and problems. Norms and values are ineluctable elements of health care, and the driving value of health care in the American setting is the sanctity of life as exemplified in the efforts of acute care medicine to rescue lives imperiled by injury or disease.
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From page 307... ...
A concrete illustration of the clash between a meclicaTized view of disease and health and the reality of chronic illness and impairment among the elderly emerges if one examines Tong-term care institutions such as nursing homes. In a recent study conducted during the past year, an interdisciplinary team at the University of Minnesota surveyed the residents and health care providers of nursing homes in five states to ascertain what they believed were the major impediments to their autonomy raised by residency in a nursing home.2i Only competent residents were included in the survey.
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From page 308... ...
Imperiled newborns. Hastings Center Report 1987; 17:5-32.
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From page 309... ...
{eds.) Everyday Ethics: Resolving Dilemmas in Nursing Home Life.
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From page 310... ...
Illness mental and otherwise. Hastings Center Report 1973; 1:19-40.
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