Does A Just Society Use the “R” Word?

Does A Just Society Use the “R” Word?

Posted on Saturday, December 13th, 2014 at 10:24 am by lifemediamatters

Courtesy WikiMedia Commons

Courtesy WikiMedia Commons

U.S. healthcare spending is poised to grow at an average of 5.7 percent annually over the next decade, stretching government budgets with an upswing in the economy, an aging population and expanded coverage under the Affordable Care Act. By 2023, healthcare spending will account for nearly a fifth of annual GDP, up from 17 percent in 2012.

Justice requires a percentage of GDP be spent on healthcare and a clear designation of covered basic services. This approach invokes the “R” word, the third rail of all discussions about the future of health spending. The principle of distributive justice, one of the four tenets of medical ethics, requires equal treatment of all patients and equal allocation of resources. Fairness not only permits, but requires, a health system to ration -not exclude- effective medical services that some may need if it is to serve all.

We are a collective moral society. There is no reason to exclude certain members of this society from access to basic medical services due to one’s ability to pay. The cardinal merit of rationing is that it guarantees that spending for all members of society will remain within the limit justice prescribes. The trajectory for cradle-to-grave healthcare places an unsustainable burden on this country’s fiscal health. Since healthcare is not the only factor determining the health of an individual or a population, it is our moral responsibility to set limits and allow other determinants of health to be funded.

Social contract theorist John Rawls argues the principles of justice are made in agreement with those entering into a contract with us to form a society. He further argues there must be “fair equality of opportunity” for its members. Rawls’ definition of what constitutes a just society is reached under a “veil of ignorance.” This veil pre-supposes that “no one knows his place in society, his class position or social status; nor does he know his fortune in the distribution of natural assets and abilities, his intelligence and strength, and the like.” Those responsible for establishing the framework for medical services would do so not knowing their ultimate personal impact, allowing difficult and equitable policies to be formulated.

Even though Rawls was not specifically considering healthcare, his theory fits. Without good health, fair equality of opportunity is compromised. If we consider ourselves a just society, we cannot exclude individuals from basic health services that strip their chances for productive lives. Without a system of rationing care, members will be excluded. And, yes, the elephant in the room is the scarcity of money.

The Independent Payment Advisory Board (IPAB), the fifteen-member panel established by the ACA to address per capita growth in Medicare spending, has deteriorated into a conversation instead of a working body. This Board became the “death panel” of healthcare reform, slipping into a coma due to the outcry from medical organizations and Congress alike.

But, realistically, “all talk and no action” must be replaced by readiness to act. We must come to grips with the competing needs for a larger slice of the fiscal pie. It cannot  be all about healthcare. Overt rationing is inevitable. However, the question remains: how do we best implement the process?

To provide basic healthcare services to everyone, a shift in the allocation of financial resources is necessary. Consensus regarding what constitutes basic care and how that cost fits within a fixed budget is required. A few examples illustrate how difficult the rationing discussion becomes when we consider where our healthcare dollars are spent and what changes may be assigned to free up resources for all.

  • In 2011, Medicare spending reached close to $554 billion, amounting to 21 percent of total health expenditures. Of that $554 billion, Medicare spent 28 percent -or about $170 billion- on patients’ last six months of life.
  • Dialysis, once a short-term bridge to transplant, has become chronic treatment for end stage renal disease and comes with an annual price tag of $50 billion, funded by Medicare and Medicaid. More than 100,000 candidates await kidney transplants on what has been called the “waiting list to die.”
  • Nearly 13% of all babies in the U.S. are born prematurely, a 20% increase since 1990. A 2006 National Academy of Sciences report found that the 550,000 preemies born each year run up about $26 billion in annual costs, primarily related to NICU care. Factor in the cost of treating the possible lifelong disabilities and the years of lost productivity among caregivers, and the real tab may top $50 billion each year.
  • Obesity in 2006 was responsible for close to 10 percent of medical costs, nearly $86 billion a year. Spending on obesity-related conditions accounted for an estimated 8.5 percent of Medicare spending, 11.8 percent of Medicaid spending and 12.9 percent of private-payer spending. By one estimate, the U.S. spent $190 billion on obesity-related health care expenses in 2005.

The list is endless, and our appetite is insatiable. From what bucket do we start to re-allocate funds to open the spigot for basic healthcare for all? The price of life matters, and how that bill is paid along the full continuum is open for debate.

Healthcare spending is not a bottomless pit. Where will the sacrifices be made for the good of society? If we adopt the veil of ignorance in setting public policy, we should arrive at a fair, albeit difficult, policy for rationing health services in a just society. Or is that just too hard for a country that repeatedly asks physicians to “do everything?”

Where Social Justice Fits In Medical Decision-Making

Posted on Saturday, November 15th, 2014 at 8:32 pm by lifemediamatters

Courtesy WikiMedia Commons

Courtesy WikiMedia Commons

This initial posting will set the stage for many essays that will be featured in this space. We all know that our current reimbursement system curtails choices for citizens, either by narrowing networks, imposing stricter guidelines for coverage or setting deductibles so high that access to care is unrealistic due to the upfront out of pocket costs required before coverage starts. There is a reason for this, and it is called social justice.

Social justice implies fairness and mutual obligation in society: that we are responsible for one another, and that we should ensure that all have equal opportunities to succeed. Being reasonably healthy is a basic necessity to succeed at providing for oneself or one’s family.

Social justice is one of the four tenets of bioethics, along with autonomy, beneficence and non-maleficence. Bioethics concerns questions about basic human values and society’s responsibility for the life and health of its members. Bioethics involves issues relating to the beginning and end of human life, from in-vitro fertilization and abortion to euthanasia and palliative care. Essentially, social justice is about fairness in a world of limited resources.

The U.S. spends 50 percent more per capita on medical care than any other country in the world, some 17.9 percent of GDP in 2010. At the same time, the U.S. achieves poorer health than many Organisation for Economic Cooperation and Development (OECD) countries. These member countries include some of the most advanced countries and various emerging ones.  From an economic perspective, curative medicine seems to produce decreasing returns in health improvement while expenditures increase.

The following is a breakdown of each dollar spent on healthcare in the U.S.:


Only 3 cents is devoted to public health activities, resulting in the neglect of many social and environmental determinants of health.

Social determinants of health are factors in the social environment that contribute to or detract from our health. These factors include socioeconomic status, nutrition, education, transportation, housing, access to services, discrimination and social or environmental stressors. More specifically, social determinants of health refer to the set of factors that contribute to the social patterning of health, disease and illness. According to the World Health Organization, “the social conditions in which people live powerfully influence chances to be healthy. Indeed factors such as poverty, social exclusion and discrimination, poor housing, unhealthy early childhood conditions and low occupational status are important determinants of most diseases, deaths and health inequalities between and within countries.” In fact, medical care alone only impacts health by 10 percent.

As a result, the discussion around social justice is becoming more relevant in medical decision-making because the cost of care is squeezing out the ability to pay for the other influencers of health. Physicians are being asked to consider not only the right treatment but also the fair allocation of scarce resources in a society of burgeoning needs.

The essays you read here will raise questions about social justice and leave you with more questions than answers. When you finish reading, you will understand why scholars and ethicists have spent decades arguing various positions. Even though bioethical discourse can become very emotionally charged, serious dialogue must be supported by strong and well-researched arguments. Pure emotion does not make for a defensible position.

This is certainly true in end of life decisions, and is as true at the beginning of life and mid-life as well.

Martin A.B. et al. (2012) Growth In US Health Spending Remained Slow in 2010; Health Share of Gross Domestic Product Was Unchanged from 2009,” Health Affairs, retrieved from

Saward, E. & Sorensen A. (1980)The current emphasis on preventive medicine: Issues in health services (pp17-29). New York: John Wiley & Sons

World Health Organization.

The World Health Report: 2004: Changing History. ISBN 92 4 156265 X (NLM Classification: WA 540.1) ISSN 1020-3311

LGBT Seniors Fear Discrimination From Caregivers

Posted on Monday, July 1st, 2013 at 12:00 pm by Life Matters Media

Dozens of seniors and medical providers crowded into the Unitarian Church of Evanston, Illinois Saturday to watch “Gen Silent,” a critically acclaimed 2011 documentary highlighting the fears many seniors in the LGBT community have about end of life care.

Directed by Stu Madduxthe film chronicles the lives of six seniors living near Boston. They go back-and-forth recounting their experiences growing up during the onset of the gay rights movement and sharing their present struggles– ranging from fears of abuse from long-term care providers to judgmental caregivers and family members.

“When someone’s facing the end of life and feeling alone and isolated it’s incredibly sad,” said palliative care physician Catherine Deamant, a member of Chicago’s End of Life Care Coalition. Many in the LGBT community are afraid to show their “true selves” to caregivers for fear of bullying, she said, and long-term care facilities tend to overlook the individual.

“Many who won the first civil rights victories for generations to come are now dying prematurely because they are reluctant to ask for help and have too few friends or family to care for them,” according to the film’s website. Oppression from the years before the Stonewall riots continues to linger with those in the film.

The audience was clearly moved by the hour-long film, with many wiping their eyes or shaking their head with disapproval at some of the film’s more emotional moments. “I find it very frightening what lies ahead of me,” one man shouted out during the discussion. “Is this another reflection of how we handle the elderly? Why should it be different for any other group?” a woman asked.

The film, similar to the 2012 Oscar-winning drama, “Amour,” did not shrink away from showing the hard truths of aging, including scenes of hospitalization and loss of strength. “I think they saw the full humanness of the people in the film– they weren’t one-dimensional,” Deamant said.

What Is A Life Worth?

Posted on Thursday, May 30th, 2013 at 2:38 pm by Life Matters Media

Geriatrician argues against bias against the aged and ill


Physicians caring for the elderly and for those nearing the end of life cannot be effective patient advocates until they confront their own deep and widespread prejudices, said geriatrician James Wright at the University of Chicago’s Conference on Medicine and Religion Wednesday.

Wright’s presentation, “The Courage to be a Geriatrician,” examined the bias held by many towards those lacking in independence, particularly those residents of nursing homes.  “Most of us share the same prejudice, that life is of less value when lived in dependency,” Wright explained. “We are in a tradition that cultivates freedom, independence and productivity, and that is what we give value.”

“We live in an era of meaningless- now that we no longer fear the sword, plague, even hell, we fear meaningless,” Wright said.

This prejudice thus serves as a blockade to administering comprehensive care to some of society’s most vulnerable- the oldest and most infirm. Medical professionals, those in geriatrics especially, must experience a shift in mindset from valuing life based on independence and instead towards seeing innate human value. The oldest and sickest are long divorced by age and ability from past functions, Wright said, but their lives remain valuable. That value does not stem from any thing they once did.

Prejudices manifest

Prejudices manifest, Wright said, when doctors make quality of life assessments. His research demonstrates that when simultaneous assessments of life quality are made by both physician and patient, the patient almost always scores his or her quality far higher than the physician.  “These devaluations matter,” he said.

The discrepancy, Wright argued, arises out of the drive of younger, working people towards self-affirmation. We often think, he said ‘‘I am not only alive, but my existence has meaning.’’ This quest for meaning is why the able-bodied join larger movements- political, civic or social. These movements give us worth.

“We live in an era of meaningless- now that we no longer fear the sword, plague, even hell, we fear meaningless,” he said, and this fear inhibits proper care of those we judge to have none.

Wright pointed towards the leaders of the Protestant Reformation as ones who can teach medical providers intrinsic human value. “All beings have equal value not because they earned it, but they were made that way by God, the source of all value,” Wright said. Both Martin Luther and John Calvin agreed that all of us, as humans, are not good enough, and fall short of our own expectations. However, God who loves without condition.

“We are enough as is,” Wright said, “and that gives us courage to be not as something greater.” The most successful providers see all life as equally acceptable and valuable, simply because that life is human.

“All people are created equal and remain equal throughout the course of their lives,” Wright concluded. “Only with this conviction, can we truly be trusted to value and care for the elderly in a way we all deserve.”

Geriatrician Shortage Unlikely To Be Remedied

Posted on Saturday, March 16th, 2013 at 7:15 am by Life Matters Media

Image: DeviantArt via Creative Commons

DeviantArt via Creative Commons

“Aging Americans are the elephant inside the demographic pyramid.”

There are too many old people in America and not enough geriatricians to care for them all, said leading elder care professionals at the Association of Health Care Journalists Conference in Boston, MA.

The rift between the growing elder population and the declining number of physicians trained in geriatrics will only grow larger in the coming years, said Sharon Levine, M.D., a professor in the Department of Medicine Geriatrics at Boston University School of Medicine.

“Aging Americans are the elephant inside the demographic pyramid,” said Levine.

With the population of those 85 and older increasing at four times the rate of other Americans, an estimated 30,000 geriatricians will be needed by the year 2030. Levine explained that this target can be hit only if 1,200 medical students enter geriatric medicine fellowship programs each year for the next two decades.

However, such entrance levels are far from likely. Only 75 medical school graduates entered geriatric fellowships in 2010, according the The American Geriatrics Society. That number was down from 120 in 2005.

Levine insists that dwindling interest in geriatrics is due, in large part, to increasing medical school debt and significantly less earning potential. In 2010, a geriatrician’s median salary was $183,523. That was almost six thousand dollars less than the average salary of a family physician, and close to $22,000 less than the average salary of a general internist. Geriatricians must train at least one year longer than their colleagues in primary care.

Currently, there are currently 3.8 geriatricians for every 10,000 older Americans. Elderly living in the Sun Belt and New England have the more geriatricians per capita in their regions than elderly patients in other parts of the country.