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By Saul Goldman
When I used to call upon people in hospitals, the conversation was about God, life or courage. Today, I listen to the worries of elderly and weakened patients facing pre-mature discharges because their insurance companies will not pay for a lengthier stay. While the twenty-third psalm recited at the bedside of a critically ill patient, may evoke images of fortitude and faith, it fails to address frustrations because of inadequate care. But, instead of demanding higher standards of training, hospitals are employing nurses trained at vocational schools. Rather than expand the cadre of nurses, hospitals are improving upon their public relations veneer. Recently, I overheard a nurse-supervisor brief her nurses on the ten things not to say to patients. In a business environment where the "message is the medium", the spit and polish facade of good public relations replaces the solidity of a medical community wherein scientists engage in healing. All this can be summarized as the latest oxymoron: health care.
Everyone is concerned about our healthcare crisis and there are various proposals on the table. Some may allow injured clients to sue their HMO. These proposals are researched by learned economists and lawyers. What, then, could theology possibly contribute toward solving what appears to be a major crisis and threat to the core of American ideology, our "inalienable right to life...." The manner in which our healthcare has been managed has proven to be inadequate, because it is mistaken. How esle could one summarize those entrusted with caring, curing and healing whose motives were profit and personal gain? Just as we are angry at a soldier who betrays his comrades and country, we have every right to be angry with a system that has corrupted the vocation of medicine, by turning it into the industry of suffering. It is, of course, the very issue of ethics that invites the theologian to a discussion of healthcare.
Like any good philosopher, we begin with an analysis of language. Whereas, religion evolved as sages sought to understand ancient scriptures, any analysis of the healthcare system must begin with a look at its language. There is a similarity of method between midrash and psychoanalysis; both scrutinize words in order to decipher meanings. Our sages taught us that within the sacred texts, there are levels of meaning from the pshat or manifest content to the drash or the meaning achieved through an hermeneutic procedure. Hence, when a rabbi listens attentively to the language of healthcare he may wonder what has happened. The new terms: HMO, utilization review, DRG, discharge planning, healthcare providers, customers and, probabilities, are all about effciency in an arena in which to be efficient follows, in order of importance, almost everything else. In caring for the sick one would prioritize: scientific accuracy, clinical judgement and skills, devotion and patience, compassion and effective communication skills, hope and perseverance.
This new vocabulary conceptualizing the new model of medical care is replacing the older form of discourse which contained words as diagnosis, patient, prognosis, consultation, care, nursing, hope, doctor and treatment. The newer vocabulary contains different terms pointing to an entirely different working paradigm. The new language is about length of stay (as if we were talking about a hotel reservation), utilization review (did it cost us too much?) and DRG's. Diagnostic related groups have replaced the word diagnosis because "group" (read market segment) is a better business concept than a unique individual. In business there is nothing unique. Customers or the market, according to researchers, conform to certain patterns and characteristics. Businessmen target a market not a person.
Once, medicine was all about the care of souls, because the Judaic ethos conceived of humankind as b'zelem Elokom (in God's image). The early physicians were priests and later rabbis because healing was more than a good deed; it was a mitzvah or imperative. As the vocation of healing became the healthcare industry, we were led to re-think our notions of what it is all about, to be sensitive to stock holders, to be mindful of costs. Hence, medical students are taught about their social responsibility, the limitations of our resources (read dollars) therefore drastically redefining persons in terms of social worth. Indeed, when people speak of that ambiguity called the "quality of life" much of its intent emerges from our utilitarian notions of being useful as a productive member of society.
Hospitals have changed their directions. Once, the chief of a hospital was the senior physician. Today, there is a sharp CEO type talking numbers, acqusitions, speaking about problems with equipment and patients in the same accounting tone of voice. Imagine an assembly line in this factory of healthcare and along the line are the surgeons and physicians as well as the para-professionals (physiotherapists, social workers etc) working upon the unit (patient) from entrance to exit (admission to discharge). The admission process goes something like this: John Smith enters the admissions lobby and gets a number on a bracelet attached so that it is not easily removed. He is taken into a room, changes into a hospital uniform and awaits the hours of testing: blood, urine, MRI, nuclear scans etc. Now John is re-classified according to his DRG. The subjective manner in which he suffers is irrelevant to the number of hospital days alotted him. In the eyes of John's HMO or insurance company, he is a hernia or by-pass or prostate cancer. Now Mr. Smith is assigned a provider, irregardless of qualifications or of any effort made at developing a physician- patient rapport. This bond of trust is often what patients need to feel better. But then, again, there is little time for bedside chats and even less interest, especially if providers (doctors) must see as many customers (patients) as possible in order to make the kind of income they once did.
There are new pre-occupations among the healthcare providers these days as well. Remember when providers were doctors? Now their concerns are capitation instead of nursing standards. Once, dcotors were angry at incompetent colleagues, now they vent their frustration upon the lawyers who represent the victims of incompetence. Sitting in on a medical ethics committee meeting, one would think they were at a legal briefing because hospitals don't seem to be as concerned about doing the right thing as they are about not doing the illegal thing. There has been a dangerous confusion between morality and law; between just and prudent. All of these changes, I believe, are consistent with the new paradigm shift in healthcare that can be described as a shift from service to sales, from the hospital as a center of healing to hospital/corporation as a source of revenue. One cannot blame the CEOs, after all they come from Wharton and the Harvard Business school, they earned their MBAs in healthcare management. Odd isn't it that one can be a hospital manager, one can control the working environment of physicians, affect the morale of nurses and patients without ever studying anatomy or physiology or pathology? What then does chronic renal failure mean other that the days allotted according to its DRG? Cardiac catherization or by-pass surgery takes on a new meaning, they are not matters of pain, anxiety or morbidity; they are length of stay and negotiated payments.
Economic analysis and improved management is not going to solve the problem because the issue is not financial; it is existential. It is not about how to make healthcare more affordable. The root of the problem is that we have abandoned our fundamental understanding of what healthcare is all about. We are employing an erroneous paradigm. Health is not an industry accessible to the formulars of macro and micro-economics. Presently, of course, shares in hospitals and nursing homes are traded on the stockmar. But, these facilities will not continue to be profitable. While we may in many respects be homo economicus, we are also a self-conscious species and eventually our consciousness will evolve into conscience. Eventually, we shall come to our senses and realize that not all things are up for sale.
Healthcare is a social responsibility and is not about making money, but all about using money to help people. This, however, is hardly an altruistic observation. Actually, it is quite utilitarian in outlook. Because even the most devout utilitarian capitalist realizes that when left unchecked, narcissm is self- destructive. Healthcare fulfills the ultimate purpose of social structure which is to care for each other, to promote the common welfare. Over the past several decades we have seen healthcare mutate into a business enterprise seeking wealth. Even human suffering could be converted into a Wall Street ticker symbol. A recent NY Times article reveals that many physicians disciplined for malpractice are easily re-hired by hospitals because they are money-makers. The connection between narcissm and indifference is obvious. Being absorbed within ourselves, the pain that others might feel, evokes little empathy and can easily become a source of profit. For years, HMOs sold health plans in which individuals were promised prescription drugs as well as physician visits and hospitalization all for bargain rates. The truth is that there are no bargains when it comes to good health and the rabbis admonish us that "a physician that doesn't charge much isn't worth much" (Talmud Baba Kama 85a). Business, of course, is competitive and sales are based upon the illusion of getting a good deal.
Some things, however, just don't fit the corporate model. And our welfare, security and life is one of those elements that cannot be commercial. The ancient Roman army allowed centurions to share in some of the spoils of war. Could you imagine the US Army Inc. deploying efficiently and cost effectively to some war zone? Can we also contemplate the absurdity of fighting this battle profitably?
The healthcare industry, like its many industrial counterparts, has created spin-off commercial ventures such as the sale of body parts or tissues. People conscientiously donate their skin, for example, to be used to save the lives of burn victims, only to have their skin sold more profitably to plastic surgeons who use it for lip or penis enhancement. DNA research, intended to pursue the origins of disease, is now used so that insurance companies or employers may maximize profits by refusing coverage to people with a genetic proclivity toward a particular illness. Knowledge pursued in order to heal has been used for control.
When a system fails we must look critically at all its parts. In the case of healthcare, the failure stems from its paradigm. We have attempted to take the very sanctity of life, a value which was to be served, and turn it into an industry that would serve us. While I would not recommend the Bible as a textbook on anatomy or physiology, it does provide incisive observations about the correspondence between life and love, longevity and goodness, between faith and healing or sickness and sin. Isaiah (6:10) saw the nation, itself, as ailing. The inadequacy of healthcare in America may actually represent our most serious national security threat. The welfare of our loved ones cannot be continuously regarded with the cynicism of what was once the sacred calling of medicine.
The Author of Exodus (23:25) and Deuteronomy (4:40) understood what later physicians were to call psychosomatic or holistic medicine. The unique entity of a person suffers emotionally and physically. Effective medicine was the right combination of emotional support and surgical technique. It might be of some interest to look at the correlation between malpractice litigation and physicians with good bedside manner. Because what all of us really want is care. There is no health without care because there is no distinction between body and soul. Writing in the Journal of Medicine and Philosophy, Irwin Lieb argued the need for a wider frame of reference in order to understand fully issues such as disease, diagnosis and treatment. Judaic thought offers such a paradigm through which a range of matters from diagnosis to informed consent or termination of life support can be analyzed.
The first hospitals were synagogues and then churches. The first physicians treated both body and spirit. The invention of the microscope and the philosophy of Descartes contributed to modern medicine in which disease was no longer a human malfunction; but, according toVirchow, was cellular pathology. The miscroscope had reduced man to the most miniscule constructions while Descartes' argument that the soul was within the pineal gland encouraged the secularization of physical medicine with the soul being left to clergy. Dissection transformed anatomy into a science and modern medicine visualizes patients through the lenses of microscopes. The intellectual revolution which transformed healing into curing because a vocation had become a science and the priest a physician has undergone a dangerous mutation in which a science has become a business and the sanctity of the priest-healer has become the efficiency of the provider.
Although the medical school curriculum must teach anatomy, physiology and biochemistry, genetics and pathology, there must somehow be room for philosophy. How else will the medical student reconnect the tissues and organs, the bones and neurons into a whole person again? Hence, a new paradigm for healthcare would restore the old language of trust, doctor, nurse, hope and care.
Theology is all about the power of words and America needs a healthcare system that would guide doctors to dedication and empower patients with hope.
from the June 2001 Edition of the Jewish Magazine
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