Health and Health Care
Efforts to enhance health care delivery systems and improve population health inevitably raise ethical issues. As health care costs rise worldwide, governments debate whether—and how—they can make health care more affordable, while also improving its quality and safety. At the same time, we know that health care accounts for only a small proportion of health outcomes. Social and economic factors such as income and education, neighborhoods with safe outdoor spaces, and foods that are affordable and healthy foods—as well as the personal choices we make—are far more consequential.
Due in large part to social and economic factors, there is a growing gap between the health of the most privileged and the most disadvantaged members of U.S. society. Yet the gaps between the health of the population in wealthy nations and the populations of poorer countries are even larger. People live much longer in developed nations, while the populations of developing nations struggle to achieve even the most basic health-related goals—clean water, adequate nutrition, and emergency health care. What do the populations of the developed world owe to those of the developing world?
How we live our lives also affects our health. Obesity is now a problem in rich and poor countries alike. How can we change the unhealthy behaviors of large populations, particularly when education alone has made little difference? Where are the lines between empowerment, persuasion, and coercion? What role should regulations, environmental redesign, and incentives play?
The U.S. health care system provides far greater financial rewards for treating illness than it does for keeping people healthy. In every other developed nation, about half of all physicians work in primary care, where the focus is on preventing illness as well as treating it. In the U.S., only one- third of physicians work in primary care, mainly because specialty care is more highly remunerated.
In addition to expanding its focus on prevention, the U.S. health care system must also improve quality and safety and rein in costs. The U.S. spends about twice as much for health care as other developed nations, but its outcomes are no better and often worse. Further, health care spending is crowding out other social goods, such as the ability to build a more sustainable environment or to provide effective education, introducing generational inequities. How much health care is necessary for human beings to flourish? To what extent should we pay for marginally beneficial treatments?
Advances in genetics and genomics and in our understanding of the needs of our aging population will raise still more questions about how best to improve population health and our health care delivery systems. For example, as precision medicine advances, how will new knowledge about what works best for individual patients affect health care costs, policies about coverage, and community health?
None of these problems is easy. However, all will benefit from careful reflection on how best to balance costs and benefits, safety and risks, competing notions of fairness, and individual rights versus community well-being.