Wednesday, March 8, 2006
The Perils of Hyperpluralism
BY DANIEL CALLAHAN

A colleague, Angela Wasunna, and I will soon see the publication of our book Medicine and the Market: Equity v. Choice (Johns Hopkins University Press). It was hard work to write that book, in great part because health policy in the United States is one of the most vexing and complicated social issues. Newt Gingrich once said that, compared with health care, foreign policy is simple, and he may be right. Over my career I have written about many controversial issues, not one of which admits to any tidy, politically tolerable solution-abortion, health care rationing, stem cell research, human subject research, controlling technology, and so on-but none seemed quite as hard as health policy.

What is different about it? Three possibilities come to mind. The first is that no one discipline can claim to have an inside track on how best to devise health policy. Health economists have a strong claim, but as Victor Fuchs noted some years ago, they had little impact in the debate on the Clinton health reform plan in the mid-1990s (it did not help that they disagreed among themselves). Though a number of prominent bioethicists were included in the famous (or infamous) work group that helped put together the plan, few if any would claim they made a difference either. Political scientists had their say, but long after the debate was over and contributing only to an assessment of what went wrong.

The second possibility is that a variety of what used to be called "vested interests" come into play in health care. American health care serves many ends other than health: jobs, exports, stock market investments, well-paid careers, corporate and personal profit . . . the list is a long one. Every one of those interests would be affected by any major reform of the present system; and everyone whose life is invested in those goodies knows it. Health care lobbyists of various stripes, led by the pharmaceutical industry, are powerful actors in Washington. To further complicate the story, they do not all have the same interests; their in-fighting can be ferocious.

The third possibility is that some deeply rooted ideological interests clash in any health care debate. At the extremes are the wholehearted single-payer universal care advocates and those libertarians who would privatize the entire system if they could get away with it. In between are those, like myself, who can tolerate some mix of government and market, but who can argue interminably about what the best mix might be. Put crudely, it is difficult to reconcile those for whom the highest value is equity (taken to require a strong government role) and personal choice about health care (taken to require a minimal government role).

The trouble with politics-which is where American health care is put together-is the usual trouble: just about everything possible gets thrown into the pot, mixed together in impenetrable and inextricable ways. Concepts such as justice and equity, choice and freedom, get thrown about with abandon, sometimes with conviction behind them, but sometimes only for rhetorical purposes. The data carefully and tediously compiled by health economists about the health and economic impact of different organizational strategies are used, or ignored, to serve the purposes of various economic interests. And even the most conscientious legislator could never find time to go through all of the relevant data, much less grapple with the Nobel laureate Kenneth Arrow's arguments about the pitfalls of trying to apply market theory to health care-or its seductions, as found in the writings of Milton Friedman. Little of that literature, or the empirical data, filters down to the public level, even if bits and pieces will make it into the media.

Someone-and I am sorry that I cannot recall who-used the term "hyperpluralism" to describe this awful, confusing, obnoxious, and unpalatable mix of ingredients that makes health care reform of any serious kind almost impossible (at least for the last 50 years). Too many things have to be changed at the same time by too many people and interests with too many different perceptions and agendas. What we have is piecemeal incrementalism, improved coverage of children (a liberal effort on the whole) but not of adults, and the George W. Bush Medicare pharmaceutical plan (a conservative effort on the whole). Neither, however, presages a clear move one way or the other in the medicine-market argument. For liberals, the improved coverage of children is still too little reform, but for conservatives of a dedicated kind, the Bush drug plan is nothing less than the conspicuous menace of big government and unmanageable budget deficits promoted by a turncoat President.

***

Can anything be done about all this by those of us in bioethics? I have a few suggestions. We might rethink the primacy of the words "justice" or "equity" as the main vehicles for introducing ethics into the health care field. Just as the language of a "right to health care" was gradually abandoned in the 1980s, lacking in political punch and too much part of a tsunami wave of claimed rights, so also justice has its drawbacks as well. It is well known, for instance, that it is harder to make a case for positive rights (the right to something, and an obligation on the part of others to provide it) than for negative rights (the right to be let alone to have our own values and live our own life). But even if the former case can be plausibly made by philosophers, its carrying power in the political marketplace is not great; good philosophical theories do not necessarily move the political will of ordinary people.

My alternative concept would be the concept of solidarity, a deep and longstanding part of the European health care tradition and the historical stimulus for its universal health care systems. It is a concept that embodies, even if not explicitly, Adam Smith's idea of the centrality of empathy as a moral value. We can all see, and will experience ourselves, the pain and suffering of illness-empathy is thus easy to come by. And we can all understand that when we are ill we will need the help of others, financially, physically, and psychologically; the value of solidarity becomes self-evident when that happens. One might object that solidarity is a European and not an American moral concept. Yet those we have tried to use in the U.S.-rights and justice-have not worked well; they elicit a poor response. We have little to lose by trying out some new language, in this case some old-country language with a good political track record.

Another suggestion would be that we think more deeply and imaginatively about the idea of interdisciplinarity. I for one have found it very difficult to find good ways of joining the language and methodologies of economics and those of ethics; and even more difficult to know how best to put that combination in a way that might make sense to a legislator (and good political science is not necessarily a help there either). As the health economist Uwe Reinhardt once noted, it is not just that "the devil is in the details," but also that "god and the devil are in the details." It is in the political arena where the details come to matter, much more than moral theory; and where the details can sometimes sway those with fixed ideological positions. But those of us in bioethics do not know well how to make the move to those details (the field has done it better in clinical medicine).

In short, can we find something useful to say about coping with hyperpluralism? Here is what would seem a key point of agreement: a good society is one that provides good health care for its citizens. The challenge is to deal with the details.

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