Monthly Archives: April 2010

Academia, Culture, Emergency Medical Services, Health Care, Politics, Public Health, Society

Health Care Costs, Quality, and Access

It is the general consensus that the structure and organization of the U.S. health care system is fractured and disorderly. For many health care consumers, especially those who rely on governmental health assistance, there is no motivation to seek appropriate care responsibly. Many of these consumers rely on the local hospital’s emergency department and municipal emergency services for their primary medical needs. The Committee on the Future of Emergency Care in the United States Health System (2006) states “[Emergency Departments] are an impressive public health success story in terms of access to care” (p. xiv), and continues to describe how the emergency departments have “become the ‘safety net of the safety net’, providing primary care services to millions of Americans who are uninsured or otherwise lack access to other community services” (p. xv). With health care comprising one sixth of the nation’s economy, doubling in the last 30 years, the focus should be to create a model of efficient and effective delivery of care so that we, as a nation, may be able to care for our sick and injured without becoming bankrupt (Kovner, Knickman, & Jonas, 2008; Mushkin et al., 1978).

As emergency medical services are considered as the health care gateway for many, allowing the emergency medical services to refer patients into appropriate pathways (e.g. primary care providers, urgent care clinics, psychiatric services) for their conditions would allow for more directed care for the patient with shorter wait times and shorter care times overall. Unfortunately, insurance providers, including Medicare and Medicaid, do not allow remuneration for such services, requiring the transportation component to trigger payment; therefore, the only option left is to transport these patients to the emergency departments. This promotes the inefficient use of such services and continues the current paradigm of inefficiency throughout the system. Though this change would increase insurance payments to emergency medical providers, increasing the initial cost of seeking health care, this would allow the provision of selecting more efficient pathways leading to more cost-effective care. Hopefully, this paradigm would result in an overall net savings.

This is only one example of modifying a current system to be more effective and help to promote efficiency throughout the health care experience. We need to consider where we can shift roles and responsibilities within the health care system in order to promote a more usable system, one that promotes integrity, efficiency, responsibility, and efficacy by both providers and consumers. Once we realize the opportunities that efficient use of current services will offer, we can realign the services to better fulfill the needs of the population where it comes to health and wellness.

References

Committee on the Future of Emergency Care in the United States Health System. (2006). Emergency medical services: At the crossroads. Washington, DC: National Academies Press. Retrieved from http://www.nationalacademies.org/nas/

Kovner, A. R., Knickman, J. R., & Jonas, S. (Eds.). (2008). Jonas & Kovner’s health care delivery in the United States (9th ed.). New York, NY: Springer.

Mushkin, S., Smelker, M., Wyss, D., Vehorn, C. L., Wagner, D. P., Berk, A., … Louria, M. (1978, October). Cost of disease and illness in the United States in the year 2000. Public Health Reports, 93(5), 493–588. Retrieved from http://www.ncbi.nlm.nih.gov/

Academia, Emergency Medical Services, Health Care, Politics, Public Health, Society

Reducing our Health Care Expenditures

With the recent signing into law of the Patient Protection and Affordable Care Act (2010), more affectionately known as ‘Obama Care’, much of the health care discussion has turned from deciding what we should do to how we should do it. Many us acknowledge that the current state of our health care needs reformation; the only problem seems to be choosing the best approach. As a licensed out-of-hospital provider, I am in a unique position to observe patients entering our health care system, being treated by our health care system, and exiting (for good or bad) our health care system. I can see that our health care needs are not being met, and I can see both how patients approach their care and how practitioners approach their patients — inefficiently and ineffectively. We need to resolve these issues.

Canada is a fairly close approximation to the United States in locale, geography, economy, and political ideology (Doran, ca. 2000; “GNI per capita”, 2010). It might make sense for us to look towards Canada to see if they have adopted a plan that we could either emulate, or, in the very least, research for a sense of best practices. Kovner, Knickman, and Jonas (2008) describe Canada as having a national health insurance (NHI) system of health care, in that the system is provisioned by a mix of both public and private contributions. Two benefits of Canada’s health care system include a high life expectancy (77.4 for males at birth) and a low cost ($3,165 per capita, or 9.9% of GDP; Kovner et al., 2008, Table 6.2, p. 165). In comparison, Kovner et al. shows that the life expectancy for males in the United States is 74.8 under a system that costs $6,102 per capita (or, 15.3% of GDP). These numbers are significant because we need to understand what we can expect from our investments, and I feel that the average life expectancy is a great benchmark of a health care system as a whole. One worry that I would have, though, is if we were to adopt the same pharmaceutical cost controls, research and development in the industry may suffer, as well as any other technology burdened by cost-cutting measures. I have to assume that the free market would effectively drive these areas, however.

In order to adopt such sweeping changes of our health care system, both liberals and conservatives would have to negotiate their ideals. I am a fairly conservative citizen who believes in smaller government and spending constraints. If reducing our health care expenditures by realigning the modes and methods of health care delivery was realistic, I could be in favor of such a reform. Political agendas aside, Canada’s health care system is certainly one that we should further consider.

References

Doran, H. (ca. 2000). Politics and political parties in Canada. Internet sources for journalists and broadcasters. Retrieved on April 22, 2010, from http://www.synapse.net/radio/can-pol.htm

“GNI per capita, Atlas method (current US$)”. (2010). Data catalog. The World Bank Group. Retrieved on April 22, 2010, from http://data.worldbank.org/indicator/NY.GNP.PCAP.CD

Kovner, A. R., Knickman, J. R., & Jonas, S. (Eds.). (2008). Jonas & Kovner’s health care delivery in the United States (9th ed.). New York, NY: Springer.

Patient Protection and Affordable Care Act of 2010, H.R. 3590, 111th Cong. (2010).

Academia, Society

My Ethical Reckoning and Edification

In my study of ethics, I have had some difficulty understanding the application of theories in light of the arguments from competing camps. I am finding it more reasonable to define my own value system, then compare this with the virtues of others. Only then can I truly appreciate the applicability of the ethical theories presented to me.

The most problematic theory is the divine command theory. In Thiroux and Krasemann (2009), divine command theory is told to be a nonconsequentialist theory derived from a set of edicts put forth by some absolute ruler of the universe (p. 54). First, I oppose their categorization. As most religions have some villainous being to rule over an underworld filled with those who violate these edicts, it seems to me that the threat of eternal damnation is certainly a valid consequence for believers of these religions. In contrast to negative consequences for bad acts, the same religions tell of eternal bliss for following its rules, positive consequences for good acts. More to the point, as Thiroux and Krasemann (2009) so aptly point out, there is no rational foundation for the existence of such a being (p. 57). I agree with this view, as it is illogical to base morality in such a weak argument.

Kant’s duty ethics appear to have more validity. Kant recognizes that we have a duty to act morally (Thiroux & Krasemann, 2009, p. 59). Unfortunately, Kant does not go further to explain how this duty has manifested. Thiroux and Krasemann attempt to explain Kant’s theory as nonconsequentialist based on absolute moral rules relying on poor logic such as the example provided, “all triangles are three-sided” (p. 57). It does not take a mathematician to understand that all triangles are three-sided purely by definition and not by reason or logic. Therefore, any absolute moral rule must be absolute by definition, and it must have a reason in order to be reasoned as such. It is these reasons, such as the continuum or failure of society, that would make this theory a consequentialist theory, and all of the duties of this theory are based solely on the vitality of society. Ergo, it would only be moral to work for society, and it would be immoral to work against it. This would be valid if there was truth in that any particular society should flourish over another. Nazi Germany comes immediately to mind.

With his prima facie duties, Ross, on the other hand, admits to consequences having bearing on choices, but he cautions that their import should be minimized when considering right and wrong (Thiroux & Krasemann, 2009, p. 62). Like Kant, Ross gives no thought to the origins of his duties, though those that he did enumerate seem to provide for the good of the individual and for society. I can certainly appreciate better the motifs of Kant and Ross over the weak foundations of divine command theory.

To more fully understand my ethics, I had to look past my mundane habits and take a truly in-depth look at the origins of my beliefs, then I had to question the motivation for each. For one, I ultimately believe that killing another human being is wrong, but do I find it unethical, and if so, to what degree. Is the taking of a human life ever ethical? Further, in order to understand my own ethics, I feel that I must analyze the basic motivations of our instincts and how we have evolved from primitive organisms into the social creatures that we are. It is this social bonding, after all, that creates this sense of morality that I am questioning.

It is understood that at some point in our development as a species, we appreciated that we were more effective as a group than as individuals competing against each other. In order to live together, we must have realized the need to develop rules and boundaries as they relate to our interactions within this social group. I believe that these rules were based on our primal needs and were focused on the benefits of banding together. For example, I mentioned killing in the last paragraph. As an early social group, we would benefit from safety in numbers over individually facing predation. If this is a benefit of social grouping, then why would this type of open competition be favored within the group? It would not. Another example would be the primal need for food versus the act of stealing. The social group would condemn stealing another’s food, thus stealing, itself, becomes taboo. This, I believe, is the reason that we have morality, and we have gotten so far from this basic understanding of morality that our own personal ethics have become confused and complicated. All of the basic moral understandings that are common in many cultures can be traced back to the first pre-societies: dishonesty, gluttony, murder, sloth, theft, and later, apathy, despondency, greed, lust, pride, and vanity.

To me, it is permissible to take a human life. It is permissible to take the life of an innocent person. One example that epitomizes this position is in the face of a torturous death. The ability to, on request, peacefully end the life of someone facing death by torture is virtuous to me. Another example would be my belief in the usefulness of euthanasia. Are these examples of murder? I think not; murder involves malice, and there is no malice in these examples. With this thought, one can still hold that all murder is unethical while killing an innocent person.

As our social system evolved, so have our needs. We are no longer few in number with common basic needs, but we are many, within many societies, and with many different needs. Though, we are still human. From our origins, as I have described, we have created our rules, a common morality that should hold true in any society, except the most exotic. Within our newly formed societies, we have prescribed rules which have evolved with our societies and have grown as societies have grown and split into other societies. Cultures within societies will augment the rules, as will the various sub-cultures. Each and every amalgam, still, has evolved from a more singular set of basic rules.

These rules must be relative to the needs of the members in order to be effective, creating a more relativist morality.

The rules of life have changed. As an American, I no longer value food, water, and shelter as much as I value my freedom and liberty. How can that be? At some point in the past, food, water, and shelter were abundant, yet people were probably prohibited or limited. Our ancestors fought hard to regain their freedom, and this appreciation of liberty has been passed down in such a way that I value it more than life, itself. This, too, is an evolution of morality. This is the point that my ethics cease to remain basic and evolve with the functionality of my society, where necessity triumphs over morality.

My understanding of morality is more or less bound to social contract theory in that, as a society, we have a better quality of life. Each decision that we make ought to reflect our willingness to participate wholly within society, lest be made pariahs. Within society and personal and business relationships, we engage in interactions that involve decision-making. It is these decisions that we consider when discussing ethics and morality. Within societies, there is competition. Competition within a society is a part of nature, part of evolution, and a healthy device to ensure survival. There are also rules within this competition. Unfortunately, our society has reversed many of these rules. As we have become more ‘civilized’, we have sought to provide a common mechanism to adjudicate morality, and in turn, project our personal ethics upon others. This is an aberration of justice, yet it is accepted as part of the process. The bane of society is regulating morality in such a way that is inconsistent with truth and integrity. We have certainly fallen far from our moral high-grounds in search of a harmonious existence.

It appears that I am getting an ‘ought’ from an ‘is’. This is correct. I feel that in order to fully understand how we ought to act, I need to know why we act as we do. There must be valid reasons. It is the same reasons that we must listen to intuition. Many early philosophers have regarded our ability to reason as the one trait that separates us from all other life on Earth. This reasoning is responsible for intuition, for gut-feeling, and it should not be ignored. If we feel that something is wrong, it is most likely wrong. We do not need to understand why it is wrong for it to be wrong, but we should accept that it is probably wrong and seek out the answer why. For someone to claim that they are a consequentialist, then examine the consequences of an act to determine if it is right or wrong is ludicrous to me. It is this cart before the horse thinking that has confused me in the classroom study of ethics. We must have faith in our ability to reason and that we have probably been faced with a similar scenario at some point in the past. Intuition will tell us so.

I cannot say that I align with any one of the three theories presented. At the same time, I can both appreciate some of the positions of each and can align with some of the arguments while I find portions of each incompatible with my views and beliefs. Every decision that we make has two alternatives to choose from, action and inaction. Though decisions can seem to be complex, they are various combinations of criteria in steps of action-inaction decision modeling. For each step, we determine the value of each decision and the higher valued path is the one chosen. Unfortunately, not many people have refined critical thinking skills to allow them to consider important possibilities that might otherwise be overlooked. The resultant anemic decision-tree usually offers little in the way of true value. For this reason, it is important to challenge one’s self frequently in the practice of making difficult decisions.

In summary, morality is based on both the individuals’ needs within a society and the continuity of the society, and there are consequences that need to be considered for each decision, some great and some insignificant. Also, a person does not have to subscribe to any particular theory in order to be moral. Any one person can feel that it is their duty to perform an act while believing in the hedonistic value of performing another act, still, while considering their benefit of performing another act. There can be no hard-line rule that encompasses how we ought to act in all possible circumstances. It is my view that we should pay more attention to descriptive theories than prescriptive theories. We are smart enough to have evolved, and we should take comfort in that.

References

Thiroux, J. P., & Krasemann, K. W. (2009). Ethics: Theory and practice (Tenth ed.). Upper Saddle River, NJ: Prentice Hall.