Bioethics Forum Essay
The Tough-Minded and the Tender-Minded
Some people are addicted to crossword puzzles, others to new shoes, and still others to collecting baseball statistics. One of my addictions is that of comparing policy arguments in very different contexts. Of late, I have been looking at three issues, each of which despite their obvious differences has some features in common with the others: health care reform, global warming, and obesity. They share an argument about the use of force. By that I mean a struggle between policies that I will call holistic and those that can be termed disruptive. Before offering some examples, let me offer a definition of the terms “holistic” and “disruptive” in this context.
A holistic policy is one that calls for very broad but incremental change to entire cultures and patterns of social behaviors. This strategy is attractive when the problem to be addressed is caused by a wide range of social practices and behaviors: when there are no “silver bullet” solutions; when the issue is politically and ideologically charged; and when it is believed that an incremental strategy will be more acceptable, less jarring and controversial, than something more immediate and forceful.
A disruptive policy might be called a brute force or blunt instrument strategy. The problem needs to be dealt with as soon as possible, not incrementally. It needs to directly achieve its chosen goals in a tough-minded way, and it is willing to put up with a political battle and popular resistance. There may be no silver bullets, but some of its shotguns will fire large-gauge projectiles, designed to cut through bullet-proof vests.
Here are my examples of what I am talking about.
Holistic and Disruptive Examples
In the health care reform debate, the holistic strategy is that of “bending the cost curve” and “getting rid of waste and inefficiency,” all of which will take time and are politically palatable. The spreading of large-scale reforms over a number of years in the Affordable Care Act, not all at once, was no less of a holistic strategy. Rationing is unmentionable to the holistic-minded. By contrast, a disruptive approach is impatient with slow incrementalism, puts the word “rationing” right out in the open, likes the idea of regular annual cuts to physician reimbursements in the Medicare program and applauds the Independent Payment Commission’s 2015 requirement of automatic cuts to the Medicare program to control costs.
In the context of the global warming crisis, holism advocates talk about the “greening” of our modern world, radically changing the way we live our lives and protecting as well the natural world: control global warming, save endangered species, and simplify the way we live our lives (stop and smell the roses). The disruptive path wants tough action to stop the annual increase of the CO2 level, a reduction of soot, strong and binding international protocols, and a forcing reduction by legislation in the use of coal or the deployment of technology to reduce the harm of coal as a major source of energy. Nor can we wait. Global warming is already with us, and irreversible in many ways, and politically tolerable incrementalism is itself a great danger.
Obesity is no less full of tensions between holistic and disruptive policy ideas. The holistic model calls for a full-court press on all fronts – educational, governmental, and commercial. The one thing not allowed, at least in the public health community, is anything that would stigmatize the overweight and the obese. They are simply the victims of hazardous work and leisure patterns, the all-too-effective advertising, marketing, and lobbying of the food and beverage industries, and a lack of regulations and tough guidelines.
But by virtue of stressing the full-court press, singling out no one overriding target, I think it fair to call that move a holistic strategy. Moreover, while there are efforts to put in place some disruptive sub-policies, most of them become softened by political and industry opposition. New York Mayor Michael Bloomberg’s push for his Department of Health to regulate the size of servings of sugar beverages met a barrage of criticism. He will most likely make his policy stick because he did not need legislative approval. He could use a blunt instrument and did. But that was one of the few occasions in this country where tough, disruptive government regulation could easily be put in place. Efforts to directly legislate taxes on fat food and sugared beverages have not gained traction. And even Mayor Bloomberg’s policy did not forbid the purchase of multiple smaller drinks.
With that brief review in place – open of course to all kinds of quibbles and counter-examples – let me declare myself. Although ordinarily a gentle, conciliatory person, willing to smell the roses and take my time doing what is necessary, in each of my three case studies I come down on the side of disruption, not holism. By the time we have bent the cost curve in health care, taking many years, our annual cost increases, even if slowed, would take us from the present 18 percent of GDP to 20 percent. And as someone who has listened for some 40 years to claims that getting rid of waste and inefficiency would obviate the need for rationing (not to mention the hazard of using that dread word), it is hard to shed some considerable skepticism.
The urgency of global warming seems to me to make the taking of small, incremental steps naive and full of illusory hopes. I concede, however, that it has been exceedingly difficult to put in place global policies and regulations, though the agreement at the Durban conference in December 2011 that the leading polluters, the U.S. and China, would be held to the same standards of global warming control after 2020, was a major breakthrough for a disruptive international policy.
As for obesity, I agree that while it is a struggle to be carried out simultaneously on many fronts, the great need is for direct government interventions and regulations with bite. Some 68 percent of our population (around 200 million, all told) is overweight or obese, and exhortation and health education programs for some decades now have not reduced its prevalence. A page-one article in today’s New York Times vividly illustrates the limits of such programs in the Bronx, where the number of overweight and obese people is growing faster than anywhere else in New York City. While there is surely a hazard in stigmatizing people for obesity-intensifying features of their life beyond their control, holistic change will no less surely require the use of social pressure.
Most important, the public must be led to accept strong government interventions in their private lives and choices and to undertake in their own lives the hard work of holding down their weight, of getting rid of excessive fat. The fear of stigmatization has hampered efforts to find acceptable means of deploying social pressure. That is my candidate for disruption.
More generally, “speak loudly and carry a big stick” is my candidate for all three of my examples.
Daniel Callahan is President Emeritus of The Hastings Center and author most recently of Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System (Princeton University Press). This fall, his memoir, In Search of the Good: A Life in Bioethics, will be published by The MIT Press and a collection of his essays, The Roots of Bioethics: Health, Progress, Technology, Death, will be published by Oxford University Press.
Posted by Susan Gilbert at 06/12/2012 02:24:39 PM |