Portal de Periódicos da CAPES

The Ethics of Excess

1994; Wiley; Volume: 24; Issue: 6 Linguagem: Inglês

10.2307/3563459

1552-146X

Richard D. Lamm,

Global Maternal and Child Health

The more I reflect on the health care system, the more I am struck by the divergence between the medical ethics of the individual and the social ethics of the health care system. We spend volumes agonizing and debating informed consent, autonomy, discontinuation of life surf port systems, and the like, but little time debating the ethics of the system. We myopically obsess about individual trees while the whole forest is being clear cut. Take my state, Colorado. Almost every hospital has an ethics committee, but no one asks ethical questions of the entire system. Over 50 percent of our hospital beds are empty; we have twenty-one hospitals doing open heart surgery, and three doing transplants (three times what is needed). We have for (for 3.5 million people) more MRI machines than Canada, and far too many specialists. This, in a state in which 450,000 citizens are uninsured and another 400,000 underinsured. We have a large excess capacity in neonatology, yet 21 percent of our women give birth without adequate prenatal care. Excess capacity sits cheek-by-jowl with great need. California is estimated to have over 400 MRI machines, far beyond any reasonable need, while 5 million of its citizens are uninsured. Half-empty hospitals in Denver hire marketing people to run expensive TV campaigns to get a market share from their neighboring half-empty hospitals, while many children go without vaccinations. Our health science center is constantly practicing supercolider medicine and looking for the next Lorenzo's oil, while in its own backyard large numbers of ordinary people lack basic health care. When asked, the well-meaning people who run these institutions all plead innocent and tell you of the good they are doing for their state. Each snowflake in an avalanche pleads `not guilty,' observed a wise friend. We all have a duty to the community as well as to the individual, yet we are trustees of a painfully inadequate system. The excesses in any one part of it are directly related to the inadequacies in another part. An individual institution may have a wonderful and thoughtful ethics committee, but the system itself does a poor job of producing health for the society. In no category (except life expectancy at age eighty) are we as healthy as citizens in Europe, or Great Britain, or Canada, or Japan. The inability to ask the larger questions of health policy and the refusal to adopt a larger ethical vision has taken a serious toll on our nation's health. Paul Starr, in his book The Social Transformation of Medicine, discusses the victory of allopathic health care over public health and the price society paid for relying so heavily on the least effective system of maximizing the health of the public. The excessive focus on the individual to the exclusion of the society caused us to train too many specialists and too few generalists. …