As you are aware, health is influenced by many factors, including but not limited to individual priorities, choices, and behavior, environmental factors, genetics, socioeconomic status, and the demands of job and family. In a prosperous, autonomy-oriented society like ours, physicians, the public, and policymakers struggle to decide how to balance caring for those whose needs are great with encouraging prudent decision-making about health behavior.
Policymakers have long debated how much assistance to give those with health care needs, and how to determine what constitutes need. This policy debate has grown hotter than ever in light of the Affordable Care Act and the continuing controversial nature of assistance programs like Medicaid. At the individual and institutional levels, health care providers are often frustrated by the complex problems of emergency department “frequent flyers” and the inability or unwillingness of some patients to do what seem like basic things: improve their diets; stop smoking; lose weight; keep appointments; seek counseling. Yet at the same time, we have a profound sense that the duty to rescue does not permit us to abandon people who make poor choices – we aren’t going to leave the uninsured, helmetless motorcycle rider to die of his head injury. Thus, health care providers are also often frustrated by the barriers they face that prevent them from providing necessary care and treatment; many of these barriers are produced by the health care system itself.
How should the responsibilities of individuals for maintaining their own health be balanced with societal responsibilities to treat those in need? And how should physicians regard and respond to patients who seem to believe that there must just be a pill that can fix whatever needs fixing – and to a system that sometimes seems unmoved by preventable suffering?
A Few Questions:
(1) Providing assistance to those with great medical need is regarded by some as fundamentally fair and beneficent, but by others as paternalistic. Those who favor helping to meet others’ medical needs may see this as simply what we should do to help people who cannot help themselves. Those who disagree argue that people should have to face the consequences of their poor choices, or they will never become self-reliant. Are these two perspectives incompatible when it comes to health care? Can you think of any way to reconcile them?
(2) How do we know what counts as a wise choice in health care? If a person has decision-making capacity, on what grounds can we challenge his or her choices without imposing our own views?
(3) We know that there are many influences on health that lie outside our direct control. Does government – local, state, or federal — have a duty to step in and make up for what people cannot do for themselves? Or is it up to non-governmental organizations like charities, churches, and civic or advocacy groups?
(4) Does it matter whether the people who lack access to health care services are currently healthy or already ill? What does it mean to “need” a health care service? Are there different kinds of needs for health care? If so, are some more important to satisfy than others?
(5) How much attention should we pay to health care in comparison to other basic needs that raise similar questions of responsibility, like employment, housing, and education?