One of the things that has troubled me for more than a decade is the way the medical profession declares that we favor an equitable distribution of healthcare resources and yet do little or nothing about it. In 2002, the Physician Charter on Medical Professionalism in The New Millennium was published. I will not bore you with the details here, but 2 provisions are important. Commitment to improving access to care and commitment to adjust distribution of finite resources are clearly stated. Physicians are exhorted to “individually and collectively strive to reduce barriers to equitable healthcare” and to be public advocates “without concern for the self-interest of the physician or the profession.”
This charter was signed by essentially every medical society and specialty organization that you can think of. From the American Medical Association to the American Academy of Orthopaedic Surgeons and the American College of Radiology and on and on. And yet, apart from lip service supporting improved access to health care, we have seen essentially no action. (I will be happy to entertain examples of such action in the comment section.)
We have theoretically signed on to the principles of universal healthcare and yet we have also been adamant in opposing and successful in preventing universal healthcare adoption. As a physician, I can find many malefactors for the lack of progression to universal healthcare in America. I don’t need to name them. You know who they are. And they will fight change with a white-hot intensity. As physicians, we can, and do, say “Why should we offer up anything when nobody else is willing to?” Maybe that is fair, but then why have the Charter? Why sign on to the Charter?
I can come up with many reasons why the medical profession has failed America in this area, but I have concluded that most important is that if we are forced to have a real conversation about universal healthcare, we will be asked to give something up and we are not prepared to do that. But until the medical profession steps up, is there really any hope?
The transition to universal healthcare will involve some pain to all of us in the healthcare industry. (Well, most of us anyway. I expect nurses, respiratory therapists, and many other categories of healthcare workers to deservedly make out a bit better, at least!) The question will be about how the pain will be divided. This terrifies physicians. It especially terrifies the highest-paid physicians. It also causes angst among the lowest paid physicians and medical students. Uncertainty is deadly to health care reform.
Consequently, I have been trying to figure out a way to have a conversation about this that makes sense and is fair to everybody. As an aside, I have been telling my generational colleagues, this is not about us. If we made sweeping changes legislatively tomorrow, most of us would be retired or at least close enough to it for any significant economic damage to happen to us.
While on my journey in cognitive science, I came across the philosophy of John Rawls. Rawls was famous for his Theory of Justice, published in 1971. At its heart is this: “A just society is a society that if you knew everything about it, you’d be willing to enter it in a random place.” Rawls proposes the thought experiment in which we place ourselves behind a Veil of Ignorance, not knowing our position in society, and then construct the society.
Rawls was one of the most influential philosophers of the 20th century and it is horribly reductionist of me to sum his work up in a few sentences, but for our purposes this will suffice. Imagine creating a physician reimbursement system and medical school tuition scheme not knowing whether you will be entering it as a radiologist, pediatrician, hospital or health plan administrator, orthopedic surgeon, or a medical student. You do not know if you will be entering at the beginning of your career or at the end of your career. How would you design the system? How much would medical school tuition be? At Georgetown? At Wright State? How much would a neurosurgeon make? How much would a psychiatrist make? What would be just? What would be fair?
I propose Rawls’ construct is a strong starting point. I can fairly confidently predict that many, if not most physicians will reject out of hand even contemplating this idea. Fear and uncertainty are potent emotions against change, or even contemplating change. But I think we can find a core of willing participants, and we can make an amazing experiment happen. We can bring these people together and have this conversation. Even if the result is just a conversation, it is a beginning. It is the beginning of a discussion of what we as physicians expect from our profession and what we expect from ourselves as professionals. Are we to “individually and collectively strive to reduce barriers to equitable healthcare” and to be public advocates “without concern for the self-interest of the physician or the profession?” Or are we to just continue to pay lip service to these ideals?
This discussion dovetails with a TED talk by Dan Ariely called How Equal Do We Want To Be? You’d be surprised. He explores economic inequality and what we think we know about economic inequality, the reality of income inequality and finally what we would ideally like income inequality to be. Please follow the link to the next portion of this writing…
