A recent Hastings Centre Report was dedicated to connecting American Values with Health Reform, given the Obama plan to reform health care for all. While Malta is planning reform, with special regard to the primary health system, very little has been said about how to connect our values to this reform. Perhaps because we take our values for granted or perhaps because it may be difficult in this day and age to define exactly what our values are. In a recent column I wrote how many persons may start considering that health care should not be totally free. Of course I came out completely opposing this view and in my little opinion, any political party considering this would be committing political suicide. This shows the different ways in which we understand the value of ‘justice’.
But party politics is not only about votes; it reflects what the people want or perceive or take for granted. We all agree that the government cannot continue to give out property the way it did. Now it is acceptable for people to purchase their own apartments. Those still under government hands are given to the disadvantaged, such as single parents who cannot work. This is a social justice based on a value which politicians recognise strikes a chord in the Maltese heart. Some may use it to advantage for votes, but the majority of politicians would truly believe in it. On the other hand politicians do recognise that you cannot kill private industry and this applies also to health care. Yet health costs are very high. A simple test can easily cost someone more than a month or two’s salary. So some form of justice has to be thought about in the provision of health care.
Now in a country which has oscillated from a socialist state to one of democratic values; from a country formerly highly staunchly Catholic to one in which Catholic thought is being questioned by many, as revealed in the recent survey done at university, one begins to question whether common Maltese values do indeed exist. Most European countries have had oscillations similar to ours and it would be interesting to find out whether the general population is in disagreement with Europe’s original position to out its Christian roots from the constitution.
Yet time and again we have shown ourselves to be consistent in certain values. We believe in Justice, even though we may argue on how to define justice. We believe in freedom and have come to cherish it because it was threatened. We still have many values which we have obtained from our Catholic faith; for example, notwithstanding the differences of faith reflected in the above survey with regards to marriage, the absolute majority of students were against abortion. Whatever surveys may say, I strongly believe that we still cherish the value of the family, even though many families are breaking down. But the call for divorce, although challenging to our faith and although many of us would not want to see it introduced, is, I genuinely believe, based on our innate nature of a strong belief in family. Those who have been separated may not have been fully prepared and or found themselves in a difficult and painful situation. For them, the chance to divorce is a chance to start over again.
When it comes to health care we all would agree that everyone should have a right to health care service. We would all agree that those at least not able to pay are to receive the same optimal health service for free. This is based also on the ethos of medicine as we understand it and not simply on charity or mercy. But even if you are well off, health care costs will run into the thousands and one may find one’s life savings demolished, as happens so often in the United States. If health had to depend on whether you can afford insurance and that your company does not go bankrupt when you are a pensioner in order to continue receiving it we all risk having people being treated on the fact of whether they were in a good employment or not. Therefore I would say that we all believe in fairness and equality, when it comes to our health.
We should be treated fairly means that health cannot depend on merit. Even if I am a drunk and a ‘bum’, or if I am homeless, I should receive the same treatment as a politician. We have challenged our fairness because it is innate in our nature to pass through windows when the corridors behind doors are too long. Yet we would all want this practice to be abolished.
The main value at stake in health care is the dignity of the human person, from the time one is born to the time one dies. We want our physicians, nurses and carers to have the integrity to treat us well not only when we have pleasant personalities or when we look good or smart. The greatness of a health care professional is shown when he or she deals with the least among the lot. But carers are not carpets on which one wipes their shoes. Sometimes we do not appreciate this and expect things out of the ordinary.
We do share a value of solidarity. Certainly health centres have not contributed to this value. They may have been good for their time, but giving a service does not necessarily mean that you have a personal doctor who can share some solidarity with you throughout the process of your illness. This is a shortcoming of not having a doctor of your choice.
We want to be equal. One may be tempted to think that the fact some go to health centres and others to their private doctor means that we are not equal. If going to a doctor meant paying the fees doctors receive on the whole European continent, then maybe there would have been a basis to this argument. But doctors charging a pittance does not render private practice inaccessible. It is however a privilege which some very few may not be able to afford, especially if one requires some tests which the same private GP can offer. Many values have been described in health care; not all may apply directly to Malta, but the following have major relevance.
Equality. In our situation, equality in health care probably means the whole thing. As a social security state we need to provide health care to all in adequate time. The time issue is the main factor, which affects our delivery. Those who can afford private health care get immediate care; those who choose state health care should get it in an adequate time frame. With the ensuing popularity of EU health law, patients can have a right to get service abroad or privately if not treated within an adequate time frame. The government (and therefore the people) will suffer more in the long run if services and waiting lists are not improved.
Justice. There are various models of justice, beyond the scope of discussion in a brief article as this. But social justice requires that we share the burden of the cost of health care. This is usually done through national insurance policies or some other form of insurance. National insurance has proved dysfunctional in either not giving enough or being put into a common pot serving other areas as well. Conversely corporate profits made by large private insurance, especially where prices are not regularised, renders this type of access expensive, and at the same time, having much of its money go to profits and not health care itself. On the other hand, if insurance is not mandatory, it will be unfair as it will prohibit people from being insured for pre-existing conditions and be laden with risk-rated premiums.
Fairness. For a system to work, we all need to contribute towards it in one form or another. Some may have a better means than others to contribute, but probably no one should be allowed not to contribute at all. In a social system, this means, that although some receive benefits which others do not, we should all pay taxes in order to make us conscious of our contribution to society and not to make some feel that others ‘ride’ the system unfairly. We should all have a fair access to insurance. Certainly, when people who can afford a knee replacement get it done within a week, while others wait over four years, would mean that the imbalance has become too large to justify.
Solidarity. Insurances are a good form of solidarity, but carry significant disadvantages as described above. Corporate profits deprive the system of much needed funds in an area that perpetually remains a scarce resource. Insurances work best when they are a national entity which is specifically directed to health care. In this way, as in Canada, for example, people who suffer from pre-existing conditions or have higher risk factors than others will not be put at a disadvantage.
Medical progress. Many have a powerful faith in science; this is perpetuated because we hear of people doing well and we also experience the benefits of health care. We therefore wish to have access to all medical progress and indeed encourage this in our research. It may not be possible however for the system to keep up with ever increasing costs. New machines and technology would have to maintain an equal access and opportunity for all. Medical progress must not seek to eliminate illness and death for these at best can be forestalled. In the meantime care for chronic conditions has gone upwards and we need therefore to focus on caring rather than eliminating diseases. It is now recognised that progress has led to unsustainable health care costs. Seeking the elimination of ageing and death has been ethically questionable therefore, as has been talk of genetic enhancements of germ line cells, while maintaining to recognise the role that genetics and pharmacogenetics play in controlling and perhaps eliminating diseases. To focus on care, we need to encourage more doctors to enter the primary care field as well.
Quality. Quality in medicine depends to a large extent on political systems. The Hastings report shows how the two extremes of communism and radical free-market policies have been disastrous for health care. Just because I have access to many investigative procedures does not mean that the quality delivered is better. Indeed it may cause undue pressure on patients. Conversely newer drugs cost much more and a cost-effective analysis may not justify their radical use. On the other hand, it is also a waste of resources to put certain drugs and investigations solely under tight consultant control. Systems need to be re-evaluated continuously in a field which is developing at a fast rate.
Efficiency. This can mean technical efficiency and the efficiency of the system. Doctors coming from specialised centres know that it is not realistic to expect a system with one non-specialised hospital, which carries therefore the burden of all specialities, to shoulder costs for a minority. Riding the shoulders of giants continues to remain a plausible alternative, where we can access specialised services abroad. Conversely I hear of tests being sent abroad because there is no fume cupboard; tests which were formerly done here and gave quite a good service.
On the other hand when we speak of efficiency the first thing that comes to mind is the waiting list. We need to ask ourselves what the realistic goals are and reach those targets. While this is easier said than done, if efficiency is to be a value of health care, its measurement, which is reasonable public satisfaction, must somehow be measured. Cooperation, between individuals within the team, between the private and public sectors, and not least between the population and the health system (such as following advice for not spreading viruses) lends itself to a more efficient system.
Stewardship. This means accepting responsibility and acting on that responsibility in order to preserve and maintain something of value – in our case the health of our population. Without health we cannot enjoy life; and without better quality of life, a health system would be meaningless. However stewardship calls for a collective conscience – it is not for a privileged few, and neither can it be based on a merit system. Someone who has smoked all his life still benefits from health services in a conscience oriented society. The person remains valuable in and of himself and even to his or her family. Telling relatives that their father cannot have all the services because he was a smoker was never acceptable in health care. We are now changing attitudes and frown upon people who abuse their health and then tax the system. We need to maintain a high moral ground and respect individuals for what they are, with all their faults, while putting pressure on life modification by health promotion, without on the other hand, ‘medicalising’ society. This calls for a good dose of realism. Stewardship means accepting responsibility towards each other and leaving it to proper authorities, like courts, to pass judgements. When health professionals make decisions based on merit or who people are, they should question whether they uphold this value of service towards humanity. It is not for me as a health professional to pass judgement. In fact, it is for me to be a patient advocate, no matter what judgements society passes on some of its members. Insurance that penalises the disabled or someone who falls ill (by increasing premiums when they have had insurance cover before the onset of the illness) have failed in their stewardship. Just as we feed the hungry, and dress the unclothed, we attend to the sick. Stewardship defines our society.
Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of Family Doctors.