Health Care: Cross Questions and Crooked Answers

A variation of Cross Questions and Crooked Answers has now achieved adult status. Political involvement in medicine has made it commonplace without our being aware of it. Let us take a statement first. It is usually worded something like this: “Every American should have quality medical care.” Now, the question, “Don’t you want the best quality medical care possible?” It is tempting to treat this as a straight question, and to make what appears to be the only reasonable answer. Namely, “Of course, I want the best quality medical care possible.” From that point on the discussion degenerates into a debate as to which is the best possible system for providing quality medical care. It may not be a futile debate, but it is apt to be inconclusive because the best points have been conceded by the answer given to the question.

This is so because “Don’t you want the best medical care possible?” is a Cross Question. It is a Cross Question which will most likely elicit a Crooked Answer. Indeed, it is what one of my professors in graduate school called a false question. A false question is one which can only be answered by giving an answer that will be in some part wrong, regardless of what angle you take on it.

To illustrate, let me give the opposite answer to the question, a somewhat perverse answer, if you like. “No, I do not want the best possible medical care. In fact, I do not want medical care at all. Medical care is not something one drools over, like a steak, the best cut of which everyone should have. I do not long for the ministrations of physicians or for the comforts of a hospital bed. Indeed, my preferences run in the opposite direction, to have as little truck with any of these as possible.”

The answer is evasive, of course, but it is evasion with a point. I want the question reworded. The first order of business is not the quality of medical care; medical care is only a means, not an end. The quality of life is my main concern, not the quality of medical care. The question might be rephrased this way: What do you want from life to which medical care (and its quality presumably) is directly related? Now that is a straight question which can be given a straight answer.

My answer would go something like this. I want the use of my faculties with as little impairment as possible. I want to see, hear, smell, feel, walk, taste, talk, and use my limbs well so that I can function normally. Why? So that I can look aider myself. So that I can manage my own affairs. So that I can be independent in order to fulfill my purpose as a man. In short, my concern with medical care is as an adjunct to my personal independence.

Restore the Patient

Contemporary medical practice has this as its primary aim. Its aim is to maintain or restore the independence of the individual, to get him up and walking again, to get him to looking after his bodily needs, to get him to exercising his faculties, and so on. The desired goal is dismissal of the patient and a minimal dependence on drugs. In short, good medical practice requires that the patient be restored to independent status as quickly as in the judgment of the attending physician he is ready for it.

Medical care cannot correctly be considered in a vacuum. When we do so we can only ask Cross Questions and get Crooked Answers about it. It is part of the larger corpus of life itself, and ordinarily a subordinate part. In the context of the statements made above, the aim of medical care—the maintaining and restoring of personal independence—is part of the broader aim of personal independence for individuals. Whatever impairs the independence of the individual will tend to be detrimental to the aims of medicine.

Government intervention is on a collision course with the best in contemporary medical practice. This may be clear to some when the matter is considered only from the angle of quality medical care, but it should be apparent to all when it is looked at from the broader angle of the independence of individuals. The purpose of medicine is to foster individual independence; the impact of government intervention is to reduce the independence of the individual and make him dependent on government. It is this case that is conceded or ignored when we focus exclusively on quality of medical care.

Perpetual Dependence

Here is a story which illustrates how government intervention tends to thwart the broader purpose of medicine by establishing perpetual dependencies. It is a true story. It is even a kind of horror story when its implications are contemplated. Here it is.

Several years ago I was living and working in Pennsylvania. My father lived in Alabama and was, when most of these events transpired, in a small hospital in Georgia. One evening, I got a call from my sister who told me that our father was very ill and that the doctor had said the family should be notified. Presumably, he was dying. It would not have been surprising, for he was 88 years old and had not been in good health for some time.

We flew the next day to see him. Two aspects of his condition stood out. One was that he had lost weight—in fact, was not far from being emaciated. The other was that he had been having hallucinations. He was conscious most of the time, knew everyone, and was lucid enough in conversation. Except, it soon became clear to me that when he was at his best he still believed in the reality of what he had seen when he was hallucinating. I spent the better part of a day at his bedside, and he seemed to want to talk about his hallucinations. (He did not call them that, of course, they were to him unpleasant things he had actually experienced.)

When I talked to the attending physician—in fact, he was the only doctor associated with the hospital—he was rather vague. His prognosis was that my father might die at any time, or he might live for a while longer. Beyond that, he only observed that it was good for me to visit with my father. I began to learn some interesting, and disturbing, things about the hospital, too. It was preternaturally quiet, and they tried to keep it that way. There were few visitors, except those who came to see my father. One did not encounter patients in the hallways, though there were several nurses about. On inquiry, I was told that the patients were all old and bedridden.

In fact, it was not what I would call a hospital; it was a nursing home with a physician and nurses in attendance, and hospital rates were being charged. Whether all the patients were being given tranquilizers, I do not know, but my father was. It was a place where old people on Medicare were brought to die.

We moved my father to another hospital as soon as we could get an ambulance. I later talked with the new physician who had examined him there. He indicated that it was too soon to make a firm prognosis but that the vital signs were all good. My father was in no imminent danger, as far as could be determined. I asked if the medication he had been given would be continued. No, the doctor said, for the time, at least, he would be taken off all drugs. What about diet, I asked. My father could eat anything he wanted, he said, and would be encouraged to eat. (He had been on a restricted diet under the other physician.)

The atmosphere in this hospital was quite different from the other one. It was alive. Patients were clearly there only temporarily for healing, hopefully, and recuperation. I was there once when the physician came in to see my father. He talked to him about going home, about his getting up from the bed, and about going hunting, which was one of my father’s favorite activities. Subtly, he was getting my father to think of getting well and inviting him back to life.

Within a day a considerable change had occurred in my father. He was more cheerful; he had begun to eat, and was beginning to do things for himself. Within a short time, he returned home to take up the normal course of his life. He lived for several years after these events, and most of the time he was up and about. The memory of the hallucinations only faded slowly, but otherwise he was better than he had been for some time.

A Cure that Kills

From what illness was my father suffering? It is reasonable to conclude, ex post facto, that he was suffering most directly from malnutrition and drug-induced hallucinations. Add to that the fear that arises from helplessness when one suspects he is terminally ill and is waited on hand and foot. The malnutrition was no doubt a consequence of the restricted diet plus an habitual finickiness about eating. There may have been some justification for the restricted diet, for he had arteriosclerosis and complained from time to time of angina attacks, though they were not usually severe. As for the tranquilizers, I can only speculate as to why they were prescribed. Father was inclined to be a noisy patient, groaning and making some loud sound when a pain struck him. The tranquilizers were supposed to keep him quiet, though they did not succeed in doing so.

More broadly, he was a victim of the Dependency Syndrome induced by government involvement in medicine. My father had become dependent on government to pay for at least a portion of his medical care. The physician had become dependent upon government for much, or most, of his income. This arrangement is conducive to the establishing of a relation of continual dependence upon medical care in the patient. For quite a while before my father had been confined in that small hospital he had gone regularly to that physician’s office for injections. There was no prospect that he would get well or be dismissed. Aider each brief session with the physician, he was let go with these words, “See you again in two weeks.”

So far as a layman may judge of such matters, that man had earlier been a competent physician. He had been a skilled surgeon with a good practice. I knew him some two de cades before the events related above, and at that time he was interested in healing his patients, getting them back on their feet, and dismissing them from his care as soon as the situation warranted it. The eventual independence of his patients was his goal.

In the interval, he had changed. He was no longer practicing medicine. He was practicing Medicare. He had bought the government’s line. Government had proclaimed, by its actions, that medical care was a good for the aged. It was a good of such importance that it should be made readily available at the taxpayer’s expense. If medical care is such a good, is it not reasonable to conclude that the aged should continually receive it? And there could be no doubt that he was dispensing a considerable amount of medical care, or something that had the look of it.

Too Much Care

But medical care is not a good. It is, if I may so phrase it, a “bad.” Drugs can have disastrous side effects. Diets can starve. Lying in bed, even in a hospital, can have debilitating effects. Dependency on doctors, nurses, and medicines is unwholesome. True, a skillful physician, with sound and independent judgment, attentive to the condition of his patients, can use medicine, diets, hospitals, and all the other paraphernalia of modern medical practice to good effect. This tells us, too, what is good: it is the skill, the sound judgment, the independence, and the careful attention. That is the good for which we should pay, and, having had to pay, we are reminded that it is scarce and should be used only when there is some need.

The quality of medical care is a secondary issue. What is at issue primarily in the thrust of government into medicine is individual independence. The great aim of medical practice is not to provide medical care; it is to restore patients to whatever status of independence is possible. The best medicine is sometimes no medicine at all. However, that decision should not be made by dispensers of medical care but by medical doctors of independent judgment. Government intervention reduces the independence of physicians and of the population generally. A physician may still heal a particular disease, but he cannot restore the full independence of a man who has become deeply dependent on government. The doctor in the small hospital was not on a collision course with government; he had accepted the dependent status of those whom he treated and was bent on perpetuating it.

It is not my purpose here, however, to dismiss the question of quality. Once it has been placed in the broader context to which it belongs—the quality of life—it can be properly considered. No doubt, most people would like to have a high quality of treatment when they stand in need of medical attention. Thus, some observations on the impact of government intervention on the quality of medicine are now in order.

Why Intervention Fails

The tendency of government intervention is to increase the quantity and reduce the quality. It does so for three reasons mainly.

First, by removing or reducing the cost factor in medical treatment, it increases the demand for it. Given the same number of medical personnel, the result is longer waits in doctor’s offices, less attention per patient in hospitals, and a dilution of the quality of what is received.

Second, when government prescribes standards of treatment they are, and must be, minimum standards. To put it another way, whatever standard government prescribes becomes the minimum standard. The way this works was well illustrated in housing. Most houses built over the last thirty or forty years have four inches of insulation above the ceiling. Much of this is blown-in insulation. Why? Because F.H.A. required four inches of insulation, and that is what most houses got. It was widely claimed that the F.H.A. requirements became the standard of the industry. They were, of course, minimum (and inadequate) standards, something the rising cost of energy has helped to bring to our attention. (The F.H.A. standard having been discredited did not, of course, lead that organization to retire from the field. It has simply set higher standards which, in turn, become the minimum standard.) A similar development is occurring in the generic drug movement. If the F.D.A. and other agencies are successful, minimally effective drugs will become the standard. To the extent that government pays for medical attention, it will be in accord with minimal requirements. Open heart surgery with a triple by-pass, will be open heart surgery with a triple by-pass, and that is what will be paid for. In short, far from providing the highest quality medical care possible, we will tend to get the lowest quality which the law allows.

Third, government intervention tends to restrain and inhibit innovation. No standards can be set for that which does not exist, and no price scales can be devised. We are experiencing already the slowdown that results from having to gain government approval before new drugs can be put on the market. The testing requirements are already so prohibitive that men will tend to turn their energies away from trying to innovate. The same restrictions do not yet apply to procedures, but there is an inhibitive tendency there also.

The Quality of Life

This brings us back, however, to my original point. The quality of medical treatment cannot be fully considered as separate from the quality of life in general. The innovations which raise the quality of medicine are themselves a product of the independence and freedom of individuals. Reduction in the independence of individuals by restrictions must inevitably result in lower quality medical treatment than would otherwise have been available. But medical treatment itself is but an adjunct to the independence of individuals.

In the final analysis, then, there is one straight question that can be asked which, when it is answered straight, provides the answers to the subordinate questions as well. It is this: Do you want that quality of life which is possible when individuals are independent? If so, you will want as well the availability of the highest quality of medical treatment.