or Public Work?
Two Perspectives on Health Care
Bruce Jennings and Mark J. Hanson
Reprinted with permission from the Bioethics Forum, Fall 1995,
pp. 3-11. Copyright 1995.
Jennings, MA, is executive director of the Hastings Center, Briarcliff
Manor, New York, and is a political scientist by training. He
is also a member of CPN's Health editorial team. Mark J. Hanson,
PhD, is associate for religious ethics at the Hastings Center
and is trained in ethics and religious studies.
today's debate over health care reform implicitly views health
care services as commodities. This economic point of view obscures
morally important features of health care and of the medical profession.
By viewing health care service instead as a public worka civic
activitywe recapture its true purposes and are better prepared
to debate health policy, health reform, and ethical medical practice
is sometimes defined as the academic study of ethical issues arising
in biomedicine and the life sciences. That definition is accurate,
but too narrow. Bioethics is also a form of civic discourse, an
essential component of what John Dewey called "social intelligence,"
particularly regarding our practical grasp of value issues inherent
in medicine, biomedical technology, and health care. So conceived,
the task of bioethics is to make arguments in public about the
social goals of medicine and how medicine should serve both individuals
and the common good.
of this essay is to discuss two ways of understanding health care
as a culturally defined activity: health care as a commodity (the
commodity conception) and health care as civic or public work
(the civic conception). Distinguishing between health care as
a commodity and as a public work is one way to address the place
of medicine in society and the place of bioethics in civic discourse.
These two notions lead discussions of system reform in different
directions. Neither notion is new; both have historical roots
in Western medicine and in the politics and economics of the modern
rival conceptions underlie much of the current normative debate
about the health care system and the profession of medicine. Recently,
the commodity conception has been winning. As it waxes in our
discourse, concern for the community wanes, and we neglect the
civic dimensions of health and of caring. Future work in bioethics
of the sort that we ourselves are engaged in will be devoted to
preserving and nurturing a civic conception of health care, although
bioethicists of a conservative or libertarian bent will disagree
with this approach. But all those who work in bioethics, regardless
of political orientation, must be aware of what is at stake in
this struggle and the implications for the shape of the moral
imagination in America. It is important to be explicit about presuppositions
underlying the goals of health care that inform health policy
and bioethics (Annas 1995).
role of the commodity conception is evident throughout the United
States health care system. It leaves its mark in the explicitly
market-oriented proposals being circulated by the Republican leadership
in Congress and among conservative think tanks. Liberals who favor
single-payor plans and those who support some version of "managed
competition," such as the ill-fated Clinton plan, also view health
care as a commodity (a service) that should be equitably distributed
among, and privately consumed by, individuals. The commodity conception
cuts across public or private sector financing mechanisms, and
it also cuts across the spectrum of egalitarian to libertarian
theories of distributive justice and equity. One reason why we
have had such a narrow and unsatisfying health reform debate is
because both liberals and conservatives take a commodity conception
for granted. We believe that seeing health care as public workas
an activity that is fundamentally civic in its nature and purposeprovides
a richer normative foundation and guiding vision for health policy
and ethical medical practice.
will proceed in three steps. First, we pose some general questions
about the nature of health care and why these questions should
be brought into public debate. Next we contrast the commodity
and public work conceptions, arguing that the commodity concept
obscures morally important features of health care, while the
public work concept places those same features squarely in view.
Finally, we turn to the role these notions play in health care
reform, with particular reference to the fate of the Clinton plan.
Lessons of the recent past illustrate an urgent need to recapture
and reassert fundamental features and commitments of health care
as public work.
is Health Care?
Two things are
striking about the situation of American medicine today. First,
the American way of conducting public policy debate and civic discourse
has failed to cope with the challenge of health system reform. The
Great Health Reform debate of 1994 was, in Daniel Yankelovich's
apt phrase, "the debate that wasn't" (Yankelovich 1995). The public
was misinformed and frightened by the debate and finally estranged
from it. A large majority of Americans saw serious flaws in the
health care system, but their sense of "personal trouble" was never
translated into the comprehension of a "public issue" (Mills 1959).
The proper language and imagination were lacking to make that translation.
Now that the political moment for comprehensive governmental reform
has passed and policy makers are frantically returning to the cost-shifting
maneuvers that make up business-as-usual in the federal and state
health policy arena, the private sector has taken over. A remarkably
rapid and far-reaching structural transformation is taking place
as the private sector restructures health care financing and delivery
through vertical integration and capitated managed care. This may
be happening with even less public understanding and meaningful
debate than the Clinton plan called forth.
At the same
time, the profession of medicine is adrift and demoralized, sensing
that doctors individually, and the profession collectively, are
losing control over the conditions of medical practice. Much as
Paul Starr predicted in The Social Transformation of American
Medicine (1982), the medical profession is beginning to succumb
to the process that sociologists refer to as "proletarianization,"
that is, doctors are better understood as sellers of their labor
in a so-called labor market (like other workers and occupations)
than as autonomous professionals dedicated to an ancient tradition
and to a special ethical calling. The same could be said about
other professions in America today; medicine has simply been the
last and most powerful profession to see its hegemony challenged.
are disturbing. We believe the confusion over health policy and
the crisis of professionalism in medicine are linked: they flow
from the same source. Health reform debate is confused because
those engaged in that debatepolitical leaders, special interest
groups, the citizenry at largeliterally do not know what they
are talking and arguing about. These are fairly sweeping claims,
and we obviously do not mean to deny the expertise and enormous
body of data and information at the disposal of both health policy
makers and health care professionals. The confusion in the discourse
surrounding American medicine today exists because we have not
addressed the question of what health care is and what it should
be. What kind of human activity is it fundamentally? How does
it fit into other forms of life and other practices that make
up the fabric of our society and culture? What is the most coherent
and normatively appropriate way of characterizing health care?
with questions such as these is not that they are vague and unanswerable,
but that they are answered tacitly and through acquiescence or
presupposition rather than openly and critically. Confusion comes
from the fact that culturally and historically, American medicine
is undergoing a significant shift in what we understand the fundamental
nature and purpose of health care to be. We are straining to adjust
older conceptions to emerging institutional and economic realities:
torn between competing ways of understanding health care; daunted
by the prospect of bringing into the open assumptions and conceptions
normally at work beneath the surface.
both a challenge and an opportunity for the field of bioethics
in the coming years. Bioethics performs few social or intellectual
functions more important than that of critically analyzing our
presuppositions about the nature of health care that shape public
discourse, policy approaches, and institutional practices. To
do this, however, bioethicists may have to concentrate on more
than simply "ethics." They may also need to examine the philosophy
of medicine and the social and cultural underpinnings of medicine's
In the past,
bioethics has been reactive and ameliorative rather than fundamental
and critical. Bioethicists have responded to issues and dilemmas
that were artifacts of biomedical technology and fee-for-service,
sub-specialized medicine. Bioethicists have rarely questioned
the institutional structures that were background and context
for ethical dilemmas resulting from competing moral principles.
Bioethics also has lent an important voice in support of human
rights and patients' rights. But rarely has it examined the implications
of undermining professional discretion in medicine, assuming that
if doctors didn't have power, then patients would have it. It
is only now becoming clear to bioethicists that empowerment of
patients does not necessarily follow from disempowerment of physicians.
Idea of a Commodity
How do we now
focus and sharpen our understanding of the fundamental nature of
health care? What is it exactly that our society is attempting to
organize (or reorganize) when governmental and corporate leaders
restructure the "health care system"? If we can't answer this question,
how can we tell whether our leaders are doing a good job? And what
are doctors and other health professionals doing when they deliver
"health care" to patients? If we can't answer this question, then
how can we tell the difference between taking away arbitrary power
from physicians that society ought not grant them, versus destroying
a moral identity and calling in medicine that society ought to protect
As we have
said, the dominant way of conceptualizing health care in policy
and even in bioethics discussions today is to see it as a commodity.
To conceive of any good or service as a "commodity" involves three
exist in exchange relationships;
2. the value of commodities and exchange relationships is instrumental;
3. commodities can only be privately or individually consumed.
is something that is traded or exchanged between distinct parties
whose relationship is created by the exchange. Commodities don't
exist apart from distinct relationships based on exchange; and,
conversely, exchange relationships don't exist unless and until
the objects or services involved in the transaction are understood
as commodities. Commodities are not the same as gifts and they
are not the same as acts of love, fealty, honor, or service. We
note these distinctions because these terms are appropriate in
different kinds of contexts and relationships. Commodities are
thus what philosophers have called "institutional facts." That
is, they are potent social realities and not just illusions, but
they only make sense within a particular social context. To ask
if health care should be seen as a commodity is to ask, in part,
whether we want the dominant relationship in health care giving
to be an exchange relationship between providers and consumers.
Is that really all there is or should be to the relationship between
physicians and patients. Or between health care givers and citizens?
in commodity exchange, both the good or service exchanged and
the exchange relationship itself are of only instrumental value
to the parties involved. They are means to an end. The provider
is interested only in the relationship with the consumer insofar
as the consumer has something of value to the provider (usually
money). The consumer is interested in the relationship only because
it is a means to gain access to the commodity or service he wants
or needs. The interests, wants, and needs of both parties exist
prior to the relationship and the commodity exchange. They are
instrumentally served (or not) by the relationship, and they will
persist through time to create the need for future exchange relationships
of the same type. In other words, the exchange relationship is
something extrinsic to the selfone passes through it, uses it
as a means to some other end, and then moves on. Again, to ask
if the commodity conception is appropriate for health care is
to ask if health caring as a practice or as a human activity is
adequately described as an extrinsic and instrumental relationship
of this kind.
notion of a commodity carries with it the notion of private consumption.
By that we mean that commodities are not simply used, they are
used up. Commodities exist to be consumed, to be individualistically
appropriated. To the extent that one person consumes a commodity,
someone else cannot. The concept of a commodity fits naturally
in a situation of natural or artificial scarcity where resources
are to be broken into discrete units and distributed across the
members of a group or population for consumption. A commodity
is something that ceases to exist as it is consumed.
Care as Public Work
of public work or civic practice contrasts with the concept of commodity
on each of these three points. Public work and commodity are different
lenses for viewing the activities of healing and caring. But then
again, the metaphor of a lens is too passive and static; it does
not capture the dynamic, constitutive quality of these conceptions.
Better to say that these conceptions are alternative interpretations
of practices that have the cultural power to transform the practices
they interpret. As we convince ourselves that medicine is a commodity,
it will eventually turn it into a commodity because it will elicit
the cultural and social responses that commodities typically elicit.
A knight is a knight in chess because competent players move and
counter it like a knight. A verb is a verb in a natural language
because competent speakers use it grammatically like a verb; a noun
becomes a verb when it is treated like a verb. (To be "tasked" with
a task, tasks us.) The same dynamic of transformation can apply
to the notion of medicine as public work as well. Caring can be
a public work if we make it so. This is not about naming or labeling;
it is about ways of living and ways of world making.
we wish to draw can be introduced by an example. Consider something
that typically would be understood as a commodity, and conversely
something that most definitely would not. A bag of cookies that
one divides among a group of eager children contains commoditiesthe
more one child gets, the less another will get. The relationship
the cookies have created among the children (and the adult dispensing
them) will cease to exist as the cookies disappear. When they
are gone, the children will cease being consumers and go back
to being playmates.
how should the sacramental wafers and wine used in Christian churches
at Holy Communion be understood? Communion is one of the major
liturgies in the Christian tradition, and liturgy (Gr. laos-people
+ argon-work) means the work of the people. This is not the place
to discuss the theological doctrine of transubstantiation. However,
considering only the material reality of the wafers and wine and
what they symbolize in the liturgy (the public work) of the church,
they are not commodities; and it would be fundamentally misleading,
theologically and sociologically, to think of them as such (Price
and Weil 1979). What they symbolize and what they are believed
to do in and through the community of people who share them, is
just the opposite of the three notions associated with the concept
of a commodity.
Eucharist does not create exchange relationships among the people
taking part or an exchange relationship with God. It is a mutual
sharing in and a joining with a larger dimension of being than
any of the participants, acting alone and without the liturgy,
could attain to by themselves.
it is not an instrumental transaction or relationship; its purpose
and value are not defined in terms of the satisfaction of preferences
or a quid pro quo. One is not "buying" forgiveness when one takes
part in the liturgy, and neither God nor the church is "selling"
the material supply of wafers and wine might conceivably be used
up, what is really being shared and dispensed in the Eucharist
(call it love, grace, forgiveness, or redemption) cannot be. Its
abundance is not diminished incrementally by each communicant
because that abundance is not consumed. Indeed, it grows the more
it is shared.
be sure, this liturgical example is tendentious in the sense that
it draws from a centuries-old religious tradition that places
it in the sharpest contrast to the modern notion of commodity
and economic exchange. Nonetheless, there remain secular practices
that resemble more closely the liturgical understanding of sharing,
community, and relationship than they do the commodity conception.
These are the secular practices that are called civic practices
or public works.
establish relationships among individuals that are not transactional
or consumptive but involve a cooperative and participatory effort
to produce something of common value. This value is not appropriated
exclusively by one of the parties to its creation, no one is simply
a "provider" or a "consumer," and the value is realized by communities
as much as by individuals. In fact, a "community" is nothing more
nor less than a fabric of relationships formed by public work.
That is why it is appropriate to call them public or civic works.
Moreover, these cooperative practices are productive, not exchange,
activities, and they require intentional, intelligent effort on
the part of all those involved in order to produce something of
public value or significance. Therefore it is appropriate to call
them public work (Dietz 1994).
care, examples of these facets of public work are more widely
manifest than simply in the area traditionally known as "public
health," where the collective goods of controlling infectious
disease and eliminating environmental sources of illness are central
goals. Of course, these traditional functions of public health
are instances of important public work, as are the more recent
public health strategies in response to infections, such as HIV
and STDs, that can only be controlled by modifying individual
behavioral risk factors (Beauchamp 1988). Beyond public health,
though, the dimensions of public work we have in mind also extend
into areas of primary and preventive medicine, where maintaining
wellness enhances the quality of life of both individuals and
entire communities. Chronic and long-term care are also primarily
public works since the main purpose is not the technical one of
curing disease or eliminating biologic dysfunction, but rather
the shared enterprise of rehabilitation, making a new life lived
with and in spite of the chronic disabling or debilitating condition
(Jennings et al. 1988; Jennings 1993).
of communities will we have in an aging society if we forget the
ways in which mutual vulnerability and dependency can bring us
together rather than drive us apart? If aging and disability are
treated as "enemies" and "stigmas" only, then the commodity counter
of medicine will never be able to provide us with enough ammunition
to fight them off. Dependency and limitations can also be symbols
of a common fate and a shared mortal humanity; rising to their
moral challenge is public work of the most significant kind. A
metaphor for medicine and health care that obscures these moral
and human realities is worse than philosophically inadequate;
it is socially pernicious. We maintain that the commodity conception
is dangerous in exactly this way.
the Right Moral Questions
best addresses the things we want to say about health care and medical
practice? The commodity conception certainly fits the mainstream
framework of today's public policy debates. Health care is routinely
characterized as a marketplace good, subject to economic valuations,
utility calculations, and the market and regulatory mechanisms of
commodity exchange. Individual consumers (rather than patients)
are viewed in relation to health care providers (rather than to
physicians or care givers). Within this framework, consumers think
of health care in terms of economic free choice, product quality,
and individual entitlement. Ethically, this conceptualization has
focused attention on distributive justiceemphasizing fair procedures
and outcomes, resource utilization and allocation, and financial
health care as a commodity, however, blinds one to what is distinctive
ethically about organized medical response to illness in a social
context and to the practice of caring in a community. Providing
care for another person is taking part in a shared endeavor, one
that would not be possible without drawing upon broader resources.
These include the technological, educational, and infrastructural
resources of the society, certainly, but also the cultural and
symbolic resources of the community that invest healing and caregiving
activities with meaning. In this sense, giving and receiving care
are no more private or individualistic than playing in a symphony
orchestra or running for elective office. The sick rely upon a
community that offersthrough medicinecaring, healing, dignity,
and the assurance that they have not been excluded. This is more
than pain relief, more than the application of technology to treat
pathologies. While this point is understood in Europe, we have
difficulty grasping it in the United States. This, more than details
of financing, is what distinguishes our health care system from
as secular liturgy or public work, health care represents a commitment
of the healthy to care for the sick. The political and moral will
to support such a public work comes about not simply because people
fear they one day may be sick, but because they sense their human
connection to others. We engage in public works because we are
a part of one another. Untreated disease, uncompensated disability,
and untended suffering in a community diminishes not only the
individuals who suffer, but the community as a whole. According
to this view, health is a state of individual and communal wellness
and well-being, a state attained both through actions one takes
in life and through relationships, structures, and communal fabric
that connect people. Unlike the commodity conception, the public
work conception makes it impossible to be healthy (or sick) all
by yourself. We can only be healthy or sick together. This conception
is vital for acute care, but even more important for the coming
realities of an aging society: chronic illness and long-term care.
Thus, when individuals are healed the entire community partakes
in that healing.
between caregiver and patient is a response to human needs that
extends beyond the individuals involved. It nurtures morally significant
ties between those who suffer illnesses and those who care for
them. This relationship has an impact on the health of the entire
community as it carries out the hard work of healing (making whole)both
morally and physically those who share in it.
Health Care Reform Off at the Impasse
administration's efforts to reform the United States health care
system attempted to change the way American health care is financed
and delivered. It expressed a social commitment to provide universal
access to health care. Moral dimensions of the issue were not
ignored. Hillary Rodham Clinton's health care reform task force
included an ethics working group, assigned the task of articulating
moral principles to inform the new health care system.
were carefully thought out, intended to describe the ethical properties
of the system the Health Security Act was aiming for (White House
Domestic Policy Council 1993; Brock and Daniels 1994). However,
they were simply tacked onto a system built upon the notion of
managed competition within a global budget. This system presupposed
the commodity conception of health care. Clinton's reformers never
seriously attempted to articulate alternatives. Consequently,
bioethics was put in the position of devising a normative framework
for evaluating alternative distributive schemes within a commodity-based
system. Here bioethics became a servant of the commodity conception
rather than its critic. The question of whether or not the American
people wanted to start from an economist's vision of health care
as a commodity never was posed.
plan was a mixed system that relied upon a combination of market
mechanisms and government regulatory systems to deliver health
care. Universal coverage was to be achieved through mandates upon
employers to provide care through contracts with regional health
care alliances. These alliances would have introduced price controls
and some consumer choices through competition for provision of
attractive and affordable benefit packages. The government also
would have provided subsidies for small businesses, coverage for
the unemployed, and continuation of Medicare. Although this mixture
of government and private sector mechanisms seemed to mean less
government control and restriction of choice than single-payer
options, it nevertheless relied upon new regulatory institutions,
mandates on business, and government controls on spending.
Security Act perished in Congress during the summer of 1994. The
Republican victory in November meant an end to comprehensive health
reform via federal legislation for the foreseeable future. Reasons
for the failure of the Clinton plan were many. The plan involved
complex, new institutions untried elsewhere. Employer mandates
were perceived as a threat by small business owners, and spurred
fear of increased unemployment. Health care budget caps invoked
fears of waiting periods and limits on treatment availability.
Proponents and critics alike concede that mistakes were made in
the political handling of the plan, from secrecy of the task force
to delivery of a 1,312-page proposal to Congress. The plan's breadth
and complexity made it a target for interest groups that opposed
any part. In the end, interest group politics succeeded in convincing
people that they would end up paying more for less.
resolutions fail, private revolutions often arise to respond both
to the need for, and to the fear of, social change. The private
revolution in American medicine is comprised of financing through
capitated fees and prepaid group practice, and increased control
by payors of patient access to providers and services.
care has become a major focus of attention in bioethics. Too often
it is assumed that managed care is synonymous with treating health
care as a commodity. This need not be the case. Managed care,
as one way of organizing health care financing and delivery is
compatible with understanding and valuing health care as public
work. If we set priorities and goals for medicine in these terms,
bioethicists would have something constructive to say about the
organization of managed care institutions. The purchasing power
and economies of scale of large organizations could be coupled
with HMOs dedicated to comprehensive care and rooted in the communities
they serve. "Publics" need not always be defined geographically;
communities of shared risk and coverage form new publics with
common interests, and these mini-publics are what HMO and point-of-service
managed care plans create. We have not yet treated them as publics
with work of their own to do; we have treated them as individual
consumers. We shouldn't conclude that it has to be this way, however,
until we have tried to make it otherwise. Moving from the individualism
of the fee-for-service, the indemnity insurance environment poses
civic opportunities as well as civic dangers.
It is too
early to judge the effects of private managed care. Further change
will be needed to alleviate the economic burdens that continued
growth in the health care sector will lay on the overall economy.
But what these recent reform attempts do indicate is that taking
the commodity conception for granted as the presupposed starting
point for all reform proposals does not work. It does not engage
the full range of concerns that people have about the place of
health care in communities and in their lives. Americans care
about efficiency and cost in health care, but that is not all
Americans care about. The evolution of managed care will have
to rely on both conceptions of health care to be at least sustainable
that the fundamental questions about health care that philosophical
integrity, moral responsibility, and political prudence compel
us to ask are best facilitated by the civic conception. These
are not too esoteric or technical to be addressed by bioethicists
as civic discourse, broadly conceived. It is the civic questions
that people listened for, but did not hear, in 1994. They are
still waiting and if these questions are posed by our society's
leadership and by the medical profession, people at the grassroots
level will engage and respond. It is in communities, after all,
where people actually do get sick and get well, where they care
and are cared for.
future of American medicine will depend, we are convinced, not
on how clever we are at efficiently managing and distributing
health care as a commodity, but on how creatively medicine and
health care institutions can reclaim and exercise their civic
imagination. It will depend on how ably they can carry out the
essential public work of creating communities through healing
diseases, compensating for disabilities, and promoting the health
of the individuals who compose them.
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