Friends:
A recent NY Times article by Dr. Sandeep Jauhar (Access at: http://www.nytimes.com/2010/03/30/health/30risk.html?ref=health) got me thinking...how accountable can anyone really be for choices that they make? The quote that is compelling:
"...But personal responsibility is a complex notion, especially when it comes to health. Individual choices always take place within a broader, messy context. When people advocate the need for personal accountability, they presuppose more control over health and sickness than really exists. Unhealthy habits are one factor in disease, but so are social status, income, family dynamics, education and genetics. Patient noncompliance with medical recommendations undoubtedly contributes to poor health, but it is as much a function of poor communication, medication costs and side effects, cultural barriers and inadequate resources as it is of willful disregard of a doctor's advice...."
It's true, when you stop to ponder it, all of our free will choices occur in the complex matrix of our lives. Even in community - even in the most caring and supportive of communities - each and every one of us makes choices about our daily lives and how we are going to live them. How often do we focus on the interdependence of our lives? How often to I stop to consider that my choices ultimately affect your ability to choose for yourself? How often do I engage in socially irresponsible behavior(s) that will ultimately affect how I interact with your sphere (e.g., talking on the cell phone while driving, not eating right or getting enough exercise, living a life with too much stress)? Hmmmm...
Often in the routine days of delivering care to those in need, I came across persons who had neglected their health and then got into trouble and wanted to be fixed. I came up against this most forcibly when I was working with a liver transplant program. Approximately half of the potential recipients were alcoholics - they had destroyed their livers through excessive ethanol intake. Now, the program required contracts and 6-months of sobriety before being listed for transplant, but I found myself in a spiritual/ethical crisis, wondering if this was a "good/appropriate" use of a limited resource. I struggled with this question/ethical dilemma for months, and finally came to peace with it through the concept of redemption.
The Abrahamic faiths all believe in a God of redemption and unqualified forgiveness. It is especially near to Jews and Christians this week as Passover and Easter are celebrated. Thus, if someone asks for forgiveness it is granted. How then, could I judge another's heart and ability to be redeemed? They had forsaken alcohol and had changed their lives, and were now seeking what help the medical establishment could give. I had taken an oath to do no harm and to seek to help others to the best of my ability. It was not/is not in the ethical code of a pharmacist to judge the acceptability of another human - only to care for them.
The debate about health insurance and coverage for those with "pre-existing conditions" and who have lacked basic health services is similar. Many are of the opinion that those who are sick or who have engaged in "unhealthy" behaviors should pay more for health insurance. Unfortunately, these are exactly the persons who can't afford to do that (similar to giving loans to poor countries who are already shackled with too much debt). That is, those people who daily have to decide whether to buy medications or food, are faced with a decision that is socially unjust and needs to be addressed by the rest of us. It is clear that providing health care through E.D.'s is costly, episodic, and does not improve the situation.
Insurance is supposed to share the risk widely so that no one person or group shoulders the burden. A final quote from Dr. Jauhar:
"...The whole point of insurance is to reduce risk. When people inveigh against the lack of personal responsibility in health care, they are really demanding a different model, one based on actual risk, not just on spreading costs evenly through society. Sick people, they are really saying, should pay more. Which model we eventually adopt in this country will say a lot about the kind of society we want to live in."
What kind of society do you want to live in? Freedom of choice and freedom in general demands a level of self sacrifice. How will you choose?
Peace!
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