The Need for a New Outlook on Healthcare

by Sylvia Engdahl

Almost everyone believes that America's healthcare system is badly in need of reform. It's generally agreed that medical care is too expensive, that some people have little or no access to it, that too much of the money devoted to it is wasted through inefficiency and corruption, and that not enough funds are available for research. These things are true. But that more money would lead to better health does not necessarily follow. There are certainly cases in which lack of insurance imposes great hardship on individuals. But on the whole, more money might well result in more medicine that is not merely unproductive but, in the opinion of some, counterproductive.

An appalling amount of money is already being spent: $3.6 trillion in 2018, which accounted for 17.7% of Gross Domestic Product (GDP). It's estimated that this will increase to nearly $6 trillion and over 19% of the GDP within the next decade. Is devoting so much to medical care worthwhile? According to a 2019 poll, three quarters of Americans say they pay too much for it and are concerned, as am I, that healthcare costs will result in significant and lasting damage to the U.S. economy. Nearly half, even among those with high incomes, fear that a major health event could result in personal bankruptcy. And though about 45% of the general population believes that the quality of care in the U.S. is the best or among the best in the world, that is not true. Among 36 other developed nations, the U.S. ranks 28th in life expectancy.

Various solutions to the crisis in healthcare costs have been proposed, all of which are not merely controversial but divisive. Unsurprisingly, only 8% of those polled believe that a bipartisan agreement can be reached on how to pay those costs. Yet all the argument has been focused on paying for the same amount of healthcare as we have now--or more. It does not seem to have occurred to anyone that the root of the problem is that we have too much of it.

To be sure, in recent years concern about the damaging effects of overdiagnosis and overtreatment has been expressed by an increasing number of physicians. It is beginning to be recognized that providing care that people do not need often does them more harm than good. As Dr. Atul Gawande, bestselling author of Being Mortal, wrote in The New Yorker, "Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse."

However, this awareness has not penetrated our society, As in my science fiction novel Stewards of the Flame, the pubic solidly supports an excess of healthcare, erroneously believing it will make them feel better and live longer. In part, this is the result of the idea that the unceasing pursuit of health is a moral obligation, discussed in my essay "The Worship of Medical Authority." But it is also due to common misconceptions about what medical care can accomplish and what priority it should be given.

Moreover, cost is not the only problem connected with healthcare today. There are also ethical issues. A growing number of people, including knowledgeable physicians, feel that medicine now has the ability to intervene where that may not be desirable--most prominently, in terminal cases where dying is painfully prolonged. This is a situation that many of us find deeply disturbing. Others are disturbed by high-tech intervention in reproduction, or by screening policies that brand people as defective or unemployable. The prospect of genetic engineering, too, has raised questions about whether medicine should do all that may become possible. And finally, there is increasing concern about the pharmaceutical industry's promotion of treatment for minor complaints, or mere risk factors, in order to create a market for unnecessary drugs.

Medical ethics has become a major field of inquiry about which a great deal has been written. Its premise, however, is that all the power attributed to medicine is indeed technologically attainable, and that whatever restraints are imposed upon it will be social. Rarely if ever is it suggested that problems and/or anticipated problems are the result of unrealistic expectations and the actions to which they lead.

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Here are some of the assumptions underlying most people's view of modern medicine.

* The science of medicine has already led to significant increase in human life expectancy, and it is likely that it will achieve further increases in the foreseeable future. FALSE. Historians are agreed that the major extensions of life expectancy that have occurred were due not to medical science, but to improvements in sanitation, nutrition, and so forth. Some point out that even these weren't what defeated airborne infectious diseases--the people without genetic resistance to them simply died out.

For the past hundred years the public has not expected their lives to be disrupted by widespread contagious disease, but experts knew that there would probably be a new pandemic sooner or later.

* Infectious disease has been defeated by medical science, except for the recently-arisen threats posed by AIDS and Ebola; we can expect to permanently eradicate all such disease if we apply enough money and effort to the task. FALSE. It has long been conventional wisdom that medical science can deal effectively with infectious disease and that its main problem is finding a way to be equally successful against chronic disease. But recently, we've begun to realize that claims of victory over infectious disease were premature. It's not just AIDS that has brought about this realization, and not even just the decreasing effectiveness of antibiotics. Attention is finally being given to the fact that microorganisms evolve much faster than humans do. [Update: When COVID-19 struck In early 2020, we learned that this is all too true.]

* Although medicine has been less successful in dealing with non-infectious diseases, it is steadily making progress against them. The war on cancer is slowly being won. Even now, the incidence of the major killers such as cancer and heart disease can be significantly decreased through preventative medicine. CONTROVERSIAL. That deaths from "risk factor" diseases can be significantly reduced by known measures is far from certain, although the majority of today's experts claim that prophylactic drugs and lifestyle changes are efficacious. The facts if examined objectively do not support this assertion, and there is reason to believe that political and commercial considerations have a good deal to do with its promotion.

* Gene therapy can be expected to eventually produce cures, or at least effective treatments, for most chronic diseases; it will be only a matter of perfecting appropriate technology. Even before cures are achieved, it will be possible to accurately compute each person's risk of developing such disorders. FALSE. It's now recognized that the complexity of gene interaction is much greater than had been supposed, and other factors affecting susceptibility are being discovered through the new science of genomics. While we will be able to genetically predict and/or cure certain diseases, most illness, even when genetic predisposition exists, doesn't involve "defective" genes.

* The human body is a biological machine that needs regular maintenance, not only with respect to supplying its needs, but in the sense that the condition of its parts should be periodically checked. If defects in parts are detected soon enough, they can often be repaired. Even when, due to medical ignorance, this is not yet possible, such checking leads to valid assessment of health. CONTROVERSIAL. The question of whether the machine metaphor is appropriate for the human body is a major philosophical question that has been debated for centuries, and there is now vocal resistance to it on philosophical grounds among advocates of "holistic" medicine, among others. Moreover, there is also new scientific evidence that the body is not a machine--at least not in the sense that term is generally used--in addition to the evidence that as a practical matter, medicine based on the machine-maintenance concept doesn't work (and sometimes results in harm).

* Someday we will be able to repair all body parts or replace them with new ones. When that day comes, human lives can be extended indefinitely if society chooses to do it. Medical progress can be measured in terms of advancement toward that goal. CONTROVERSIAL. This idea is closely tied to the previous one. If the body is a biological machine, it's reasonable to expect that all parts can ultimately be repaired or replaced, and that this will result in health. If it's not a machine, there are no grounds whatsoever for such an assumption. (Could this be one reason for the popularity of the machine model?)

Much had been said about the role of the parameceutical industry in promoting drugs that are not necessary, but people still take them, even when it means financial hardship.

* Medical technology has provided us with a marvelous array of effective drugs, the increasing use of which has made us the healthiest society in human history. It is constantly developing betters ones. If taken under the direction of a physician, these drugs are generally safe and beneficial. FALSE. This assumption too is related to the "machine" issue, because medication of parts is conceptually equivalent to tinkering with them. However, there are also many practical reasons to question the overall benefits of our growing prescription drug use, indispensable though drugs are in certain cases. There is really no such thing as a drug "side effect"--effects are effects, whether or not we're aware of them, and to single out the one we want as the "primary" effect is unrealistic. Some drugs carry serious risks, and though this may be the lesser of evils compared to the illness they are intended to treat, no one should take them without awareness of those risks. Further, the question of whether a given drug is better than a placebo depends on more understanding of placebos than science has yet attained. On top of these considerations, there is very real reason for concern about the impact of the pharmaceutical industry on information presented to doctors.

* Although some functional disorders have psychological components, the causes of organic illness are exclusively physical. In any case, the progress of such disease is wholly physical and is not affected by what goes on in the patient's mind. If "spontaneous" improvement occurs, it must be initiated by physical factors medicine hasn't yet identified. FALSE. Although many doctors still believe this, it is being overthrown by science, especially through the new field of psychoneuroimmunology (PNI). There is no longer room for reasonable doubt--state of mind affects the immune response, among others. This has been proven with animal experiments; controlled studies are more difficult to design with humans, but evidence is slowly being acquired.

* Perfect health is the natural state of the human body, and illness is a sign of something having gone wrong. It is the result of defective components, poor environmental conditions, and/or unwise lifestyle (or, in the case of psychosomatic disorders, of faulty psychological functioning). All of these are in principle correctable; a sufficiently advanced society would have no illness. FALSE. It's human nature to equate illness with "something wrong" --this has been done in all cultures, and in ours it's built into the language. Creationists believe God made us perfect and New Agers believe we "make our own reality;" our ills are seen as the result of sin, bad karma, or personal shortcomings, but always as in conflict with our true nature. Strangely, medical science too operates under this premise while at the same time giving lip service to our evolutionary origin. Yet there is nothing in the evolutionary process that works against illnesses not relevant to reproductive fitness, and a good deal that promotes them--for example, one may be a protection against another that is worse. Recently, theorists have begun to address this issue, which is important because of its implications for what we can expect of medicine.

* The distinction between health and disease is a matter of scientific analysis. Virtually all health problems are due to specific diseases with specific causes, which in principle can be identified whether or not they can be cured. In most cases their fundamental mechanisms are known, although there are still many details to be filled in. FALSE. In many cases the definition of "disease" is a social, rather than scientific, issue, although medicine claims sole authority to decide it. As for causes of disease, the only sure thing that can be said is that in most cases they're far more complex than has been imagined. Those to which chronic diseases are attributed are generally partial and based on speculation, or at best, on mere theory. Statistics purporting to identify causal relationships often reflect mere associations. And medical tests, even when accurate, are no more reliable than the premises on which they're based.

Increasingly, some doctors are warning that screening and examination of people without symptoms often does more harm than good, but many patients demand tests and checkups anyway.

* It is better to hunt for indications of possible disease than to wait until symptoms appear because if it exists, treating it early will result in the best possible outcome, and will save money. CONTROVERSIAL. In the first place, unnecessary testing may in itself do harm; many diagnostic tests are not risk-free. In the second place, screening produces false positives, resulting not only in unnecessary anxiety but sometimes in unneeded treatment that is damaging. Moreover, it often uncovers abnormalities that would never progress to significant disease, and treating them may prove harmful as well as costly; this is something more and more doctors are becoming concerned about. And finally, contrary to common belief "preventative" care does not save money because providing it to the people who would never become seriously ill costs more than treating the minority who do.

* It is known what constitutes a healthy diet, and everyone should follow the official guidelines that describe it. FALSE. There is no single kind of diet that is right for everyone; this is why there are so many conflicting claims about diet made by different experts. Not enough is yet known about metabolism and the genetic influences on it to determine what is healthiest for individuals, so the only way to judge is by what works best.

* Although we can't yet cure or effectively treat all illnesses, it is better to do something about them than to do nothing. Whether or not suffering can be relieved--and sometimes even if it's increased by treatment--there is no legitimate reason to forgo treatment entirely. FALSE. This view is characteristic of modern medicine, at least in America; doctors and patients alike consider it axiomatic that "you have to do something." But in fact, there is no good reason to believe this. It's in part a matter of preference; though personally, I'd rather put up with sickness than with hazardous remedies--and for that matter, I'd rather die from a disease than from the "side" effects of well-meant intervention--I'm apparently in the minority. Beyond personal feeling, however, is the likelihood that such intervention, if not of proven reliability, may do more harm than good by thwarting the natural processes of the body. Where we lack sufficient understanding of those processes to develop an effective treatment, we certainly haven't the knowledge interfere with them, except where relief of symptoms is judged to be worth whatever risk may ensue.

* The standard procedures of medicine have a firm basis in science. Most physicians are knowledgeable about the scientific foundations of the treatments they prescribe, and about new scientific developments that are relevant to them. Where controversy exists among doctors, conscientious ones base their opinions on personal evaluation of the existing evidence. FALSE. Most doctors are not trained as scientists. They are trained to follow the accepted practices they're taught in medical school, and later, read about in medical journals. Thus they often assume that there's more evidence for standard tests and treatments than actually exists, when in fact, many of these have never been subjected to controlled clinical trials, and the statistics, if any, that support them fail to isolate all the relevant variables. Further, malpractice standards are set by prevailing views and are specifically biased against dissenting ones; so even the best doctors practice according to what the medical establishment, with its growing bureaucracy, decrees

* The recent trend toward "evidence-based medicine" will eventually assure that all approved treatments are based on scientific evidence and will therefore benefit all patients to whom they are given. FALSE. Evidence is a matter of statistics. A trial can do more than show that one drug or treatment works better than another, or better than a placebo, for a significant number of people. This does not mean it will work for everyone, and there will always be individuals who would be helped more by the alternative against which it was compared. Therefore, some people may be harmed by strict adherence to the evidence. Doctors and patients will always need to exercise personal judgment.

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Our culture expects doctors to deal with all physical problems, althuogh medical technology is more appropriate for some types of illness than others.

Every one of the above assumptions is either false or controversial, and in my opinion they are all false. So why is the acceptance of them by the public so widespread? To be sure, they are more or less built into our culture--it's a bit like asking why people in the Middle Ages believed the plague was sent by God. A list of assumptions about health and illness can be composed for any culture, and observers from subsequent cultures are likely to feel they prevailed simply because nobody knew any better. In a sense, this is true.

But the deeper question is, how did these particular assumptions come to be accepted by our own culture? One reason is that medicine did indeed take spectacular steps forward in preventing and curing infectious diseases. Although it was not primarily responsible for increasing life expectancy, and although its victory against infectious disease may prove to be short-lived, it did within a few generations defuse the daily threat posed by such diseases. To the public at large, the distinction between one type of illness and another is not at all clear-cut, so it was natural for people to base expectations for the future on past results. Even now, most people do not grasp the fundamental difference between invasion of the body by external organisms and problems in its internal functioning--for example, they picture cancer cells as invaders, even when they know that cancer, though sometimes engendered by environmental factors, isn't an attack from outside. It does not occur to them that technology might be better suited for use in one situation than in the other.

Medicine also made great strides in the repair of injuries and in surgical technique. Again, the technology was so effective that distinctions in the nature of its application were obscured. An injury results from an external cause. So does an infected appendix--it has been taken over by invading microorganisms. But to the average person, and even to many surgeons, a bad appendix is no different from an organ damaged by cancer or malfunction; if a surgical cure can be effected in one case, why not in the other? Certainly, there are situations in which surgery for conditions of internal origin is lifesaving--I have had such surgery myself, so I'd be the last to dispute its value. And there are others in which repair of parts is entirely appropriate. But, though there may be further advances in this area, their usefulness will have limits.

Extension of hope from cure of externally-caused problems to cure of internally-caused ones is understandable. But there is far more to the public's faith in medicine than that, and It's more than mere wishful thinking. In my essay "The Worship of Medical Authority" I have discussed what underlies it in some detail. It is not likely that widespread attitudes toward healthcare will change in the foreseeable future--those doctors who now see the harm in unnecessary or futile testing and treatment report that it is the patients and their families who demand it.

So what can be done? The most promising approach, I think, is first, for individuals to understand what medical care can and cannot accomplish, and not ask for the impossible; second, to be aware of the risks of tests and treatments--especially newly-developed ones--and ask their doctors to explain them; and finally, think about what their priorities really are. Despite all the controversies connected with healthcare today, there is one major issue that is never raised: Is it true that maximum health is the highest priority for everyone? Or do people simply accept, at least ostensibly, the social consensus that health must be valued above all else?

The ongoing use of medication has become so common in our society thst many people view it as a necessity even when future health is not their top priority.

It's obvious that not all of them act as if it were. People are constantly exhorted to exercise more and eat less appetizing food, and few of those who fail to do it doubt the questionable premise that such lifestyle changes actually reduce the risk of illness--rather, they feel the guilt that society places on them. Yet their real priority is to enjoy their lives while well. There is nothing sinful in that, any more than there is in engaging in dangerous sports or devoting long hours to work against medical advice. It's a matter of personal choice. Why then do so many who have no intention of prioritizing health visit doctors when they're not sick and take "preventative" medication that reduces their quality of life, financially and sometimes physically, thereby driving up the price of care for those who really need it? If we were all honest about our priorities, both the cost and the harm from unnecessary care would be reduced.

In fact, if people stopped worrying about their health and what they are doing, or failing to do, to preserve it, there would be less chance of their getting sick. It is generally recognized that stress is a major cause of illness, yet seldom is this fact taken into account in indoctrination about health issues. The admonishments spread by health promoters seem aimed at scaring the public into compliance while advising the elimination of stress in general, which is at best a self-defeating strategy.

Evaluation of priorities is particularly important for people who do have a chronic disease. This is sometimes considered if they are terminally ill, but It should be addressed much earlier--and not just in cases of serious illness but in those that merely involve long-term risk factors. Doctors take it for granted that everyone wants to live as long as possible, regardless of cost and lowered quality of life; but this is not always the case. Ideally they should ask their patients, but if they don't, patients should take the initiative without feeling they would be thought foolish if their personal priorities are different. Is the goal maximum length of life or maximum quality of life? Does the person truly want to give up pleasures and/or undergo distressing treatments for the sake of living a little while longer? Or does he or she simply assume it's necessary because that's what is expected in our culture?

This differs, of course, depending on individual preference. Encouraging people to forgo medical treatment they do not really want is not "rationing" of healthcare; it is common sense. Those who do want all available treatments should have access to them--if that is their priority they should not be urged to change it. For some individuals, however, palliative care is a wiser choice than today's standard care. Contrary to a common misconception, palliative care (comfort care) is not the same as hospice care and it is not just for people who are dying--it can be chosen at any time, and there are doctors who specialize in it, though not enough of them. It simply means having treatment that maximizes quality of life instead of trying to stop the natural course of a disease.

Does age make a difference? It does in regard to people's preferences, but in my opinion it should not affect anyone's right to choose. There have been some high-profile cases of teenagers who did not want chemotherapy but were forced to have it, by which I was appalled. Why should they have been tortured at a cost of thousands when all they wanted was a chance to enjoy the life remaining to them? Meanwhile, tragically, there were people of all ages who did want treatment for illness and could not get it because they couldn't pay for it. Society cannot solve the problem of funding healthcare until it adopts a less distorted view of how the money should be spent.