Using our Cultural Fears to Create Solutions in Health Care

The Health Care Crisis and Pseudo Solutions

In 2008, Americans spent $2.3 trillion on health care.  In 2011, health care accounted for 17.9 % of the nation’s gross domestic product; it is expected to reach 20% by 2021.  If this rate of growth continues, the health care crisis will worsen.  On the other side of this financial dilemma, there lies another challenge.  As a result of the high costs of health care, Americans are not necessarily getting any healthier.  The CDC reports that chronic illnesses ‘account for 70% of all deaths in the U.S.’  Something is terribly wrong with our health care system.

            In the search of ‘mending’ a broken system, various different ‘solutions’ have been proposed.  We have failed at adequately addressing the deeper problems within the health care system.  Malcolm Gladwell wrote that we have instead “opted for a makeshift system of increasing complexity and dysfunction.”  We have focused on altering the system with a wide range of ‘solutions,’ including cutting costs (i.e. technology, end-of-life spending) to changing insurance coverage to changing the way the pharmaceutical companies address ‘consumers.’  Although these ‘solutions’ may temporarily address some of the financial and coverage issues, there are still fundamental problems that are not necessarily addressed.  Will these ‘solutions’ be useful for the long-term health of Americans if the deep problems are not addressed?  I think not.

Deeper Issues:  Our Cultural Values and Fears

Len Saputo wrote that the U.S. health care crisis emerges from “our dysfunctional cultural values,” such as “separatism, mechanism, isolationism, and fierce competition.”  Culture modulates the expression of health care, and if the foundations are weak, it will eventually impact the system negatively.  Another expression of culture that comes up on the topic of health care includes our deep cultural fears of death, aging, and suffering.  The topics of death and aging have attracted a lot of reflection.  Shannon Brownlee asked, “How can we best care for patients who are in the final stages of life?  How do we stop thinking that failing to “do everything possible” for elderly, dying loved ones is tantamount to killing them?”  T. R. Reid brought up a question that relates to our cultural fear of aging when he wrote, “Should the health system, or the insurance plan, pay for Viagra? For Botox?”

When our cultural values, such as competition and greed, are combined with our cultural fears, such as death, a lot of messiness results.  My past two blog posts (February 1 and February 15) addressed how our cultural fears of death, suffering, and aging diffuse into the health care system (end-of-life costs and the pharmaceutical industry).  It is very important for us to recognize that our cultural values and fears—or our cultural paradigm—impacts the health care system.  The paradigm not only impacts the way health care functions (or malfunctions), but it also impacts the way we create ‘solutions.’  Albert Einstein once stated, “problems cannot be solved by the same level of thinking that created them.”

The health care ‘solutions’ mentioned earlier in this post are not really helping people or improving their health significantly.  They serve as ‘quick fix’ solutions that do not really change anything.  Within the realm of health care, the ‘solutions’ may be compared to a dog chasing its own tail (at best) or they may elicit greater harm to others (at worst).  Solutions to our health care crisis that do not address our dysfunctional cultural values may not be very useful in the long-term.  Because of this, it is beneficial to look into these very things.

Creating Health Care Solutions From the Ground-Up

            It may initially seem that shifting our cultural values may be very difficult to do.  This is true, as our ways of thinking and being do not dissolve and change over night.  However, there are some practical ways of implementing new cultural values into the existing health care framework.  This would not require the total annihilation of the system we currently work with.  In this way, the solutions are built from the ground-up (starting with cultural issues), implemented into the system, and a more solid cultural shift in paradigm can slowly follow.  This allows the newer cultural values to diffuse slowly into our culture and health care system.  Once people see that the new values bring about results that work for America’s health, there will be less fear associated with changing beliefs and values.

I will discuss four solutions that can positively impact the U.S. health care system.  They can be incorporated separately, but when they are combined together, the results will be greater.

            First, patient-centered care should be the foundation of health care.  For-profit health care severely silences and abuses the real needs of the patient.  A great starting place to address patients’ needs is by looking at what we are scared of.  Within the realm of health care, patients experience a wide range of emotions and fears.  Dr. Scott Fishman wrote, “fear, a potent pain magnifier, is the dominant emotion - fear of pain, fear of death, fear of the unknown.” A patient’s experience of his or her disease is often accompanied with such fears.  Additionally, Fran Lowry summarized a palliative doctor’s stance when she wrote, “people who provide health care are so afraid of death themselves that fear compromises their ability to administer to the needs of terminally ill patients.”  These two examples demonstrate how our cultural fears can literally get in the way of patients needs.  In the first example, patients’ fears are not being acknowledged by the health care system.  In the second example, the relationship between the doctors’ fear of death negatively impacts the patient.  When a system is centered on the patient, it must adapt to, acknowledge, and address the needs of the patients.

            Second, our health care system needs to focus more on the lessons and meanings of illness from each patient’s perspective.  The fears of aging and death call up a lot of existential concerns in patients.  Past cultures have valued the exploration into such deeply personal inquiries.  Len Saputo discussed, “the deeper meaning of illness is usually unconscious.  Accessing these lessons requires a willingness to be more open and vulnerable if the deeper message is to be revealed.”  He also explained that many practitioners cannot adequately support the needs of dying patients because they have not explored their own morality.  One solution within this category includes the implementation of health education within the topic of illness.  Wolfgang Hoeschele wrote that an aim of education might be supporting others in facing their own death.   This type of education could strongly benefit sick and well patients alike because it would allow them to explore what illness and death means to them.  When these concerns are addressed in a supportive patient-centered environment, many internal shifts can take place.  If a patient feels supported, they are more likely to be open to exploring such topics.

            Third, focusing on relationships is important for a positive shift in health care.  The first relationship to consider is that of the natural life cycle.  Len Saputo explained that when doctors ‘lose’ patients, it is often seen as losing a battle against nature.  Daniel Callahan expanded this concept when he asked, “should death be seen as the greatest evil that medicine should seek to combat, or would a good quality of life within a finite life span be a better goal?”  Exploring the relationship to the natural life cycle is related to fostering other relationships.  Wolfgang Hoeschele explained that once we address anxieties concerning the self, we are better able to ‘clearly perceive the needs of others.’  Addressing our existential concerns can result in two things, namely, 1) less exploitation of human beings, and 2) a greater sense of genuine care. 

            Lastly, an honest reflection relating to the topics of illness and death has the potential of changing our health behaviors and preventative self-care practices.  In his inspiring article for The New Yorker, Atul Gawande described a doctor that created teams of health professionals, including doctors, nurses, and health coaches.  These teams worked one-on-one with the “worst of the worst” patients, who were constantly utilizing health care resources and were in very poor health.  The health turn-arounds of these patients were baffling—self-care practices emerged from simple one-on-one conversations with individuals who really cared for the patients.

Fear of Death and Greed Within the Pharmaceutical Industry

           Our cultural fear of death can be observed throughout several facets of the U.S. health care system.  Although the last blog focused on how it impacts end-of-life spending, this blog will focus on how our cultural fear of death, when combined with greed, plays out within the pharmaceutical industry.  Furthermore, there is an alternative to what we have created.

Cultural Taboos:  Suffering, Aging, and Death

Robin Hanson, a professor in the Department of Economics at George Mason University who has a major interest in health policy, explained how deeply embedded the fear of death is within American culture and what we will do in efforts to control it.  He described:

The fear of death is a powerful influence on our thinking, even if we are not often conscious of it.  Our society, like all others before it, has a strong need to feel in control of death, even if we must embrace fairy tales and quack cures to gain that sense of control.  The idea that we mostly do not understand and cannot control death is just not a message that people want to hear.  The message that medical miracles can control death, in contrast, is a message that people do want to hear.

U.S. health care (notably, the pharmaceutical industry) plays upon our cultural fear of death and strives to control it.  Daniel Callahan wrote that a cultural change is needed if we are to regulate health care costs.  Yes, there are economic and management problems within the health care system.  However, the system also contains a deeper cultural issue—we typically see suffering, aging, and death as ‘enemies.’  Callahan asked, “should death be seen as the greatest evil that medicine should seek to combat, or would a good quality of life within a finite life span be a better goal?”  The U.S. health care system has taken the first route—combating death.  Perhaps it would be beneficial to explore where this thought structure has taken us.

The Deadly Combination: Fear of Death and Greed

It is important to see how our deep cultural taboos and fears, such as death, diffuses into our health care system.  Does our cultural fear of death alone drive health care or is there something else to the puzzle?  In our efforts to modulate death, something else has entered the health care equation.  The late Professor Emeritus of Economics at Duke University, Thomas Naylor, boldly stated that American health care “rests perilously on two principles: fear of death and greed.”  When our fear of death is combined with greed, things get really messy.

            The pharmaceutical industry serves as a perfect example of what happens when greed exploits our fear of death.  First and foremost, the pharmaceutical industry is a booming business.  According to Dr. Len Saputo, the 2002 revenue of the ten pharmaceutical companies in the Fortune 500 reached $35.9 billion.  These profits surpassed the combined profits of the remaining 490 companies, which was $33.7 billion.  In this short video, ex-drug-pusher Kathleen Slattery-Moschkau explained that the pharmaceutical industry must first please Wall Street.  The industry is not based upon science, but marketing.  Advertising plays a key role.  In order to increase the potential for profit, the industry plays off of our deepest insecurities and fears.  Expanding upon this idea, American journalist John-Manuel Andriote declared, “by manipulating our fear of suffering and death, big pharmaceutical companies are able to keep us coming back for expensive medications.” 

Since profits are most valued within the pharmaceutical industry, the needs of the patients are overlooked (at best) to purposefully ignored (at worst).  Saputo summarized:

Over the past two decades, the pharmaceutical industry has moved very far from its original high purpose of discovering and producing useful new drugs. Now primarily a marketing machine to sell drugs of dubious benefit, this industry uses its wealth and power to co-opt every institution that might stand in the way, including the U.S. Congress, the FDA, academic medical centers, and the medical profession itself.

Patients’ needs have been severely compromised as Big Pharma became a ‘marketing machine.’  A major ethical issue that arises is that the pharmaceutical companies literally profit off of the suffering and sickness of Americans.  The sicker the country is, the more money Big Pharma makes.  Things that would benefit sick individuals—drugs that actually help people or health-promoting self-care activities such as proper nutrition, movement, and healthy stress management—are not Big Pharma’s focus.  Sadly, sickness is great for business.

Although it may seem that this situation cannot get any worse, it already has.  Big Pharma has intentionally created new ‘diseases’ and ‘conditions’ that play on peoples’ fears and emotions.  Lynn Payer called this ‘disease mongering.’  She wrote that disease mongers try “to convince essentially well people that they are sick, or slightly sick people that they are very ill.”  This is when our cultural fears of sickness, suffering, and death come into the mix.  A great example of this took place in the 1920s.  Melody Petersen described Listerine’s marketing tactic of “creating public anxiety” about halitus.  This word simply means bad breath, however, it was meant to sound like it may cause serious issues, such as sickness or death, if left ‘untreated.’  Of course it will not cause a person to die, however, a person who was considered ‘healthy’ now had a reason to feel that she may not be as healthy as she once thought.  Her bad breath must be treated before something ‘bigger’ goes wrong. 

This marketing strategy is still utilized today within Big Pharma.  Petersen described how the market was expanded with the drug, Detrol.  The drug company ‘created’ more potential customers by creating a new ‘health problem.’  They expanded the target market to include individuals who simply urinate frequently (nine times a day or more).  Often times, drug companies will appeal directly to the consumer.  This Detrol commercial is a good example of such a marketing technique.  Len Saputo explained that the ‘core intention’ of direct-to-consumer commercials is to “entirely bypass the medical profession and appeal directly to consumers, hoping to induce them to ask their doctors for a remedy for some real malady or for a supposed illness newly identified.”  Such advertisements play upon the fears and emotions of individuals, convincing them that something is inherently wrong with them.

An Alternative Perspective

It is very powerful to go back to Daniel Callahan’s question about whether medicine should fight against death or if a “good quality of life within a finite life span’ would be a more appropriate goal in health care.  The pharmaceutical industry has played out the former option—death has become a medicalized ‘problem’ that we fight against.  When we combine this with our cultural fear of suffering and death and Big Pharma’s greed, soon we have a system of medicine that massively profits off of the sick.  Patients are being manipulated.  Marketing and advertising based upon Americans’ insecurities and fears became the very foundation of the pharmaceutical industry. We have gone so far down this route of ‘fighting death’ and it has taken us nowhere.  In fact, the health care system and the well-being of patients are in crisis.  It makes you wonder… should we be combating death?  Look where it has taken us.

Despite this grim picture, Callahan provided an alternative perspective.  What would it be like if we really admitted our mortality to ourselves?  Would health and good quality of life become the goal of the life we do have?  Perhaps the health care system would stop focusing on controlling death, and Big Pharma would no longer need to manipulate and scare ‘consumers.’  Starting a cultural conversation about death and natural life cycles would be a great place to start.  There is the potential for real improvement if we explore our cultural fears.  This can lead us to a more patient-centered health care system that values self-care practices and health instead of sickness.  Health-promoting treatments and practices, such as Chinese medicine, nutrition, movement, stress management, and energy medicine, could become the foreground of life.  The exploration of our cultural (and personal) fear of death may be exactly what we need to do in order to learn more about life and health.  Because of this, it is finally time for the U.S. health care system to explore it as well.

Our Fear of Death and the American Health Care Crisis

It is well understood that America’s health care system is in crisis.  Access to care is an issue.  The amount of uninsured Americans has reached 47 million, and this number continues to grow.  Some people pay for health care services out-of-pocket.  In “The Moral-Hazard Myth,” Malcolm Gladwell wrote that the uninsured spends an average of $934 annually on minimal health care.  Others cannot even afford this “luxury” and go without medical care of any kind.  Additionally, U.S. health care is growing more rapidly than we can keep up with.  It is the size of Italy’s entire economy.  As of 2008, health care cost the U.S. $2.3 trillion.  If this growth continues, health care will cause America to go bankrupt.  And the icing on the cake?  As a result of all of this spending, Americans aren’t getting any healthier.  We have failed at addressing these problems, and instead we have "opted for a makeshift system of increasing complexity and dysfunction."  Such “solutions” have been plenty, and we still remain in this health care crisis.

Something has to change, but what is it?  I like to ask, where do we start?  Before talking about health care further, it is important to discuss culture.  In his book, A Return to Healing: Radical Health Care Reform and the Future of Medicine, Len Saputo wrote that the U.S. health care crisis emerges from “our dysfunctional cultural values,” such as “separatism, mechanism, isolationism, and fierce competition.”  Culture modulates the expression of health care, and if the foundations are weak, it will eventually impact the system negatively.  I think that our cultural taboos (which relate to our cultural values) also affect the health care system.  A large taboo that our culture particularly shares is our deep fear of death.  There are, of course, various ways that the fear of death can show up.  It can be fear of the unknown or suffering surrounding death.  It can be fear of having not lived to one’s expectations or leaving loved ones behind.  Either way, death is typically feared.  Another related cultural taboo includes aging.  In a society that predominantly values the young, aging is rarely seen as a "respectable,” “beautiful,” or “natural” process.  Aging, dying, and death are, in fact, consciously and unconsciously ignored in our culture.  Serving as examples, this article is about a woman who wants to be cryogenically frozen, and this paper describes the “future of death” and cryonics.  These examples are extremes, but they are intended to reflect our culture’s intense fear of death.

Although it is true that the fear of death naturally diffuses throughout our everyday culture, it is impossible to ignore death when looking directly at health care and medicine. According to Thomas Naylor, the late Professor Emeritus of Economics at Duke University, American health care “rests perilously on two principles: fear of death and greed.”  In his article, palliative care physician Brad Stuart wrote that the health care crisis itself is causing us to “confront the limitations of life.”  One way this can be seen is by exploring technology.  Medical technology has advanced so rapidly, and it has made us more aware of an alternate ‘zone’ of life. The more widespread usage of ventilators, for example, has allowed individuals to biologically survive despite not being able to breathe on their own.  Ventilators are useful for some patients.  On the other hand, these technologies have also created a new "zone" that is between life and death.  In her book, “And a Time to Die:  How American Hospitals Shape the End of Life,” Sharon Kaufman described this zone, “it is the gray zone between health, awareness, function, and viable life on the one hand, and “no longer a person,” “death in life,” or death on the other hand.  This gray zone has become exquisitely complex during the past thirty years and has spread—into new kinds of hospitals, into more patients’ lives and families’ worlds, to more medical conditions and corporeal states.”  What happens in this zone?  Doctors inform family members that the patient has a very little chance of surviving, but a very small chance still exists.  Families struggle with the news and hold onto any ounce of hope, thus deciding that any medical service and procedure should be utilized so that the patient may miraculously recover.  To ‘let’ someone die would be inhumane when a chance still exists, right?  Meanwhile, doctors, health professionals, and hospital systems have a conflicting need, as Sharon Kaufman put it, “to move things along.”  The health care system is based upon efficiency—when a patient is admitted into the hospital, it is a goal to discharge that patient as quickly as possible after receiving proper care.  However, doctors also try to do everything to save lives, which serves as the ‘heroic foundation’ needed for a medical miracle to take place.  In the documentary, “Money and Medicine,” a doctor had patient in “gray zone”.  He stated we must stop giving false hope to families, thus making it seem we can ward away death indefinitely.  Someone else commented that he is paid more for doing more even if it is not beneficial (and he strives to preserve life). Many conflicting values occur in this zone—where we modulate (or time) death itself—amongst health professionals, patients, and family members because we fail as a culture to discuss death.

There are several complications this “gray zone” is bringing attention to.  Among these topics, a big factor is money.  Len Saputo discussed that half of health care costs go toward terminally ill patients who are in their last year of life.  Although these patients may or may not have experienced the hospital-maintained “gray zone,” a percentage of them probably did.  Regarding the cost of dying, Sharon Kaufman explained that some economists and policy makers complain that it costs too much to die in America—the process of dying also goes on for too long.  In another article, Richard Lamm pointed out that many of us would do anything to save our own mother’s life.  For her, we would welcome all types of medical technologies and give her everything we can.  In response to this logic, he wrote, “you cannot build a health care system, or any public system, a mother at a time.  This is an unfair and unrealistic standard to hold public policy to.”  Thomas Naylor stated, “When human greed exploits the fear of death, there is no limit as to how high healthcare prices can rise. For those who are fortunate enough to have good health insurance, the message is, ‘You deserve the best medical care money can buy, because you are entitled to live forever.’”  Adding to the topic of economics, in “End-of-life Spending: Can We Rationalise Costs?,” Amber Barnato discussed the concept of quality-adjusted life-years (QALY).  In her article, she explained, "a year in perfect health (utility of 1.0) is weighted equally to two years in 'half' perfect health (utility of 0.5)."  Healthy individuals took the surveys and determined the quality of life they would experience if they had certain conditions.  Certain diseases had a ‘better’ QALY whereas some health issues had a ‘worse’ QALY.  This article made me think about how much economists are really thinking about death and dying.  As a country, do we want economists to make these decisions based upon poor surveying?  Do we want hospitals and insurance companies to decide when to ‘pull the plug’ (i.e. “death panels”) on our family members?  I propose ‘no’ to both questions. 

There are solutions that directly deal with our fear of death and dying.  It is probably the most uncomfortable solution, although it probably has the most useful and long-term advantages.  We need to address our fear of death.  We need to start talking about death on a very real level.  “We” includes doctors, nurses, patients, policy makers... and especially you and me.  Talking with family members is a great place to start. It may also be helpful to ‘relay’ current decisions to a primary care physician. Wills, health education on end-of-life, and a ‘more general’ cultural conversation around death will allow people to deal with emotions surrounding death.  Once we get talking about it, more clear solutions will appear.  It is quite well known that most people, when surveyed, do not want to experience a medicalized death.  They want to die at home.  What are the ‘gifts’ the “gray zone” makes us aware of in our health care system?  Are we now experiencing the point at which materialistic-based science will show us that addressing spiritual needs of patients, family members, and relatives are necessary to good health?