by N.J. Slabbert
In 1751, a quarter of a century before he helped establish the US Declaration of Independence, Benjamin Franklin was a healthcare activist. He raised £2000 in public donations — over $630 000 in today’s money — to match government funding to bankroll the colonies’ first hospital. It was a moment that continues to resonate thought-provokingly with 21st-century America, not just because it initiated American hospital services but because from the outset it identified organized public healthcare provision as a moral issue.
The hospital that Franklin labored to set up, in Philadelphia, Pennsylvania, wasn’t for the well-to-do. It was expressly to offer free care to the poor, including that “great number of persons who arrive here from several parts of Europe, many of whom are poor.” Franklin partnered prominent local Quakers on the project, which its originating document described as “a good work, acceptable to God”. A practical thinker more comfortable with the zest of everyday problem-solving than with unworldly contemplation, Franklin possessed a politician’s awareness of the persuasive power of religious argument. But he was also driven by moral impulses, a sense of transcendent values, and an altruistic imperative. Shortly before his death he wrote that he believed in God and that “the most acceptable service we render to him, is doing good to his other children”. Elsewhere he wrote of “that satisfaction which naturally arises in humane minds from a consciousness of doing good, and from the frequent pleasing sight of misery relieved.” To symbolize this humane mission, Franklin and Quaker physician Thomas Bond gave the Pennsylvania hospital an official seal referencing Jesus’s parable of the Good Samaritan.
Today the hospital has grown into a 520-bed complex that not only provides medical care to over 29 000 admitted patients and 115 000 outpatients a year but also trains doctors and conducts research. It’s part of the University of Pennsylvania Health System, a massive organization that grapples with all the challenges that confront America’s national medical infrastructure. While it still tries to honor its humanitarian roots, it’s clear that something has been lost in translating Franklin’s vision into the 21st-century economic and administrative vocabularies of the medical system and the nation that Franklin pioneered. A 2015 University of Pennsylvania Health System financial aid policy document explains that the system “must balance what is compassionate and equitable with what is financially reasonable”, that the process for non-citizens “will be handled on a case-by-case basis”, and that “patients who do not cooperate with the financial counseling process, or whose application for full financial assistance is denied by UPHS, may be pursued by collection efforts, including referral to an outside collection agency or attorney, as determined by Patient Accounting.”
The argument that Scrooges have hijacked medical care and other socially necessary services, squeezing out morality, has been strongly made by both religious and secular observers. British economic historian Richard Tawney, a devout Christian, saw the commercialization of society as corrosive to the humane spirit, while Canadian-American economist John Kenneth Galbraith (who according to Esquire magazine said he had found that religious speculation, on the whole, “adds very little to economics”) produced an impressive body of analysis which concluded that the great power of big business doesn’t necessarily translate into public well-being.
On the other hand, it’s been cogently argued that religious sentiment can not only coexist with economic impetus but support it. In an early 20th-century classic of sociology, The Protestant Ethic and the Spirit of Capitalism, German scholar Max Weber argued that the values espoused by the Protestant form of Christianity contributed greatly to the rise of capitalist economies. In our time historian Niall Ferguson has observed that Weber’s conclusions are apparently validated by the diminishing work ethic of an increasingly secular western Europe. And it’s relevant to bear in mind that in addition to performing charitable hospital endeavors, Franklin was a shrewd and successful businessman who also helped launch America’s insurance industry, which he saw as both profitable and socially useful.
What connects Franklin’s healthcare activism with our present day is the ongoing philosophical tension between morality, economics and politics. The idea that morality requires access to medical care goes back to antiquity and can be traced to various faiths which encouraged the merciful sharing of healing expertise. More than two thousand years ago healing services were offered at Greek temples. After Emperor Constantine embraced Christianity, the church’s compassionate mission drove the spread of organized medical care, a development which seems to have been pivotal in the evolution of hospitals in western civilization. The Roman Catholic network of medical institutions currently seems to remain the world’s biggest single source of medical services outside government, but although the medical profession fiercely clings to its public image as an ethically impelled corps of public benefactors, several tides of modern history have patently diluted the influence of faith-based moral considerations in healthcare policy and administration.
The secularization of western civilization while by no means abolishing morality, has made it unfashionable to promote moral arguments with the kind of forcefulness and context associated with religious teaching. The professionalization of medicine (and other disciplines) over the 19th and 20th centuries has encouraged publicly beneficial codes of conduct and peer oversight, but at the cost of collectivizing individual practitioners into power groups whose internal politics and agendas don’t always coincide with the public interest. This phenomenon is further complicated by interactions between different professional power groups. Medical policymaking is shaped by nonmedical professionals such as economists, government bureaucrats, business managers, political party ideologues, and lawyers. Massive commercial organizations such as insurers, pharmaceutical corporations and other industrial concerns have made American healthcare a lucrative industry in which profit often appears to override all other considerations.
When one surveys the immense terrain covered by public debate over healthcare policy, it’s hard to avoid the impression that one of the biggest obstacles to healthcare reform is its sheer conceptual complexity. The community of physicians is only one of the participants, and probably not the dominant one. Many power groups are involved, representing various disciplinary backgrounds and intellectual vocabularies. A clear perception of this confusion is obscured by the fact that contemporary media culture projects a greatly simplified impression of public discourse, in which superficial phrases of the moment make it seem as if everyone is sharing a common vocabulary, so that the underlying philosophical Babel goes largely underestimated. In the fictional universe of the popular science fiction entertainment franchise Star Trek there is a device called “the universal translator” which conveniently makes it possible for speakers of any language to communicate transparently with the speakers of any other. The Internet creates the illusion that, as in the fantasy world of Star Trek, everyone occupies the same mental world. This Universal Translator Myth is an enemy of public policy development, because it impedes recognition of the immense intellectual gulfs that exist between different power groups and even different intellectual disciplines, even when language is shared.
The interdisciplinary conceptual challenges posed by contemporary healthcare have taxed policymakers and scholars for generations. In a 1984 review of The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry, a Pulitzer Prizewinning book by sociologist Paul Starr (now co-editor of the magazine The American Prospect), researcher Conrad Seipp praised the work while at the same time regretting its failure to “identify or discuss either the inevitable linkages among medical enterprise, the ideology underlying its practice, and the prevailing social structure-or the ways they collectively impact on the developments he describes.” The book, he noted, “left unexplored is the possibility that the current crisis is intellectual and conceptual as well as cultural and organizational.”
Over three decades later, the US healthcare crisis is even worse and efforts to navigate it continue to be handicapped by the intellectual difficulties of integrating the diverse intellectual perspectives that must be brought to bear. Against this background, the publication of Dr Stephen C Schimpff’s Fixing the Primary Care Crisis: Reclaiming the Patient-Doctor Relationship and Returning Healthcare Decisions to You and Your Doctor is a major contribution which offers a turning point in healthcare discussion. As a clear, authoritative, state-of-the-art orientation text in one of America’s most important current public interest issues, it is a milestone in America’s healthcare reform thinking which every US presidential candidate should read.
This statement may sound extravagant, but I offer it with due consideration, for three reasons. The first is Schimpff’s credentials. Unlike many writers on healthcare and other public policy issues, he has no agenda apart from wanting to help improve healthcare. He’s not running for public office or seeking to climb a professional ladder. His long and successful career has spanned medical practice, teaching, research, advising government, and successfully running one of the world’s leading hospitals. Although he retains professor status in medicine and public policy, he’s essentially retired to his study to document and analyze the state of healthcare as he sees it. He has nothing to prove to anyone and no one to cozy up to politically. This is fortunate for the rest of us, because his mind contains a unique encyclopedia about how healthcare works and how it can be changed to serve us all better. Schimpff isn’t just another commentator. He’s a national resource.
The second reason to pay attention to Schimpff is his tone. Despite its context of crisis it is patient and calmly reasoned, marked by a note of urgency derived not from hysteria but from moral earnestness. He is convinced that we must fix the healthcare system not just because doing so will be economically efficient but because it will be ethically right. Both this conviction and the nature of the solutions he offers enable his suggestions to achieve unusual success in bridging the ever-widening intellectual gap that has grown between the moral and politico-economic perspectives on medical services. It’s this blend of moral and economic message that gives his book its philosophical importance.
The third reason to read this book is that unlike many discussions of big ideas it doesn’t leave it to others to cope with the details. Because Schimpff has been responsible for making medical services work on every level of policymaking and administration, he knows the circumstances in which doctors work most productively, both individually and in collectives.
The word “crisis” has become so commonly used that its meaning has been debased, but the primary care issue really is one. Of all the aspects of healthcare policy that need attention, this one — the lack of access of millions of Americans to a doctor with whom they can develop and sustain an ongoing health-monitoring and advisory relationship – is arguably the most pressing. It isn’t a crisis only for patients, but also for government, for all the institutions that support healthcare, for physicians themselves, and for the economy as a whole. Schimpff’s book reflects a keen grasp of this interlocking nature of the healthcare ecology, which is like a biosystem in which damage to one part can impair the functioning of a multifaceted whole. Schimpff has grasped a key fact, namely that the economics of healthcare cannot be fixed by accountants and economists alone. There must be a fundamental philosophical change in how we approach healthcare. It is widely believed that the crisis in healthcare is the result of the great expense of the necessary services, but as Schimpff shows, the crisis has not been caused by the expense; the expense has been caused by the crisis. This stems from the way our medical establishment is structured, and it can be fixed. Read this book for a fresh understanding of both the problem and the road ahead.
For more about Dr Schimpff’s book, go here.
For Benjamin Franklin’s memoir of his hospital project, go here.
To read older posts, go here.