The Organic Dimensions of Health Policy

C. D. Bessinger, Jr. MD

The health care system is a level of the larger social system, within which it must seek and find its equilibrium. This organic concept leads to a more realistic assessment of needs and goals, and can make a significant contribution in helping reshape national health policy. It also suggests a re-examination of a two-tiered approach to health benefits: A universally available level of care deemed essential for meeting social needs, and an optional coverage level directed toward meeting those individual life goals which may exceed social needs.

There has been steadily increasing pressure for a major reorganization and redirection of our national health system. There have been many expressions of the problems inherent in our current health policy (or as some argue, the lack of policy), and there are many proposals for needed solutions, summarized in a theme issue of a national journal. [1] However, if we are to resolve our current dilemma, our pluralistic and individualistic society will have to develop a consensus philosophy which focuses our thinking, shapes our structuring of solutions, structures our resolve, and provides appropriate ethics tests by which various proposals might be evaluated.

I have previously examined the implications for ethics of life-systems science, [2] drawing heavily on von Bertalanffy's work on systems theory [3] and on Engel's biopsychosocial model for medical practice. [4] It also derives from Schweitzer's concept of reverence for life, [5] which he based on a recognition of life's autonomic "will-to-live", or, in life-systems language, homeostasis. [6]

That synthesis leads us to reaffirm the organic view that life is interrelated at all levels. The "health" of any level is dependent on the homeostasis of its constituent subsystems, and of the larger system of which it is itself a part. From the life-systems perspective, the ethical imperative is to bring conscious actions into accord with the principle of homeostasis, which operates autonomically at unconscious levels of life.

I propose that life-systems analysis can also make a significant contribution in helping reshape national health policy. The long-range success of any changes will require an awareness of the principle of homeostasis. Such an idea is not merely metaphor, for the health industry as a system cannot be divorced from the multi-level life system which it seeks to serve, and of which it is a part.

Though we well recognize organic principles as the physiological basis of clinical practice, we are generally less practiced at seeing such principles in action at the social level. Yet, systems theory recognizes the multi-dimensional interactions between all levels of life. Survival requires feedback and freedom of response to challenges. Regardless of level, there are certain needs which must be met, requiring both the avoidance of harm and the ability to heal injuries when they occur. At the large-system level, maintaining the integrity of its constituent subsystems and providing diversity of responses (through complex subsystems organization) are integral to that healing and survival.

The life system also recognizes individual limits. Further, biological variation imposes a probabilistic "uncertainty principle" which limits the ability to predict outcomes of conscious actions. All of these considerations must govern decision-making, but are not necessarily addressed in more traditional systems of ethics.

The health system is a multi-level sector of the life system whose survival requires meeting the needs of its society and of the individuals it is supposed to serve. However, the complexities of the system require that many competing interests be reconciled. The life system (and its health subsystem) must provide for and integrate the whole. That does not necessarily arise from altruism (though that is one dimension at the conscious level of reverence for life), but from its neutral seeking of homeostasis.

Foremost among its needs is access by all who need the system's services, in order to avoid the harms (now readily apparent) for individuals, society, and the health professions when pain and disease are not properly addressed. Among current problems which must be removed or minimized is the mindset of patient as an adversary who must be defended against by practicing a medicine of excess. It must also minimize polarizations by class and category, which harm patients and contribute to various social stresses and instabilities.

Efficiency requires providing incentives and rewards (financial, yes, but also personal and professional satisfaction) for hard work, irregular hours, and diligent study which are basic elements in medical professionalism. The system must also be free to respond; it must provide for freedom in professional decision making, so as to minimize interference with the doctor-patient relationship. While limits and tolerances must be set at the system level, external management of decision-making at the patient level sets barriers to meeting human needs.

The system must be diverse in both the scientific and economic aspects of its health care program, to foster "learning" and adaptation to changes and challenges. The existing variety of delivery mechanisms is a strength which provides opportunities to explore new options as local and regional conditions change. Models which have proven satisfactory in small homogenous populations will not likely be as satisfactory in a large heterogeneous nation. The larger system requires additional subsystems organization, with mechanisms to reduce the possibility of injury and chaotic response if a portion of the industry were to fail.

The feedback principle indicates the importance of the public role in monitoring and setting the "physiological" limits of tolerance of the system, and responding immediately and decisively to avert subsystem failure. Monitoring must include all component subsystems (insurance funds, and individual and institutional providers), and promptly indentify areas of inefficiency and impropriety. Recent national experience indicates that there must be structural protections from the type of corporate looting which recently characterized the federally insured -- and too-lightly regulated -- savings and loan industry, and the securities markets.

The feedback principle also suggests that the system should permit funds and data to flow readily between subsystems (insurers) throughout the nation in response to normal regional "peaks", such as seasonal cycles of disease or regional economic cycles. This free-flow could be achieved by a system of inter-insurance. Each insuring fund would function in part as a re-insurer for all others against short-term losses. That is, the reserve fund "pool" would be dispersed throughout the system. Government funds would be used primarily to purchase basic benefits insurance on behalf of its entitlement program clients, but would also provide re-insurance of the inter-company "pool".

The element most conspicuously missing in the present system is a "neuroendocrine axis" for the necessary central integration of the many subsystems. That could be provided by a non-political quasi-governmental agency ("Commission") which maintained on-line monitoring of flow of funds and services within the system, and which used various software pattern-recognition techniques to identify strain-points. The commission could respond by coordinating inter-insurance funds transfers, and it would have appropriate investigatory and disciplinary powers, under careful public review. However, success of the system would depend in large measure on avoiding adversarial relationships.

It is not realistic to expect a national health system to lower health care costs, if access is extended to one-hundred percent of a growing population. However, in the long-term view, and equitable health system is necessary for the stability and survival of the social system at large. The system must somehow accomodate whatever an equitable system costs.

The present difficulty is not those essential costs, but excess cost. Planning must emphasize meeting appropriate cost, and avoidance of excesses. The current unbridled medical liability system is a major contributor to excess costs, of proportions sufficient to prevent a national health insurance system from reaching homeostasis. Success of a national health program will require achieving a fair and appropriate no-fault liability system. [7]

Universal access to care is unquestionably an expensive concept, and it brings us directly into confrontation with limited resources, for appropriate health care is only one essential of a homeostatic society. Here too, life-systems analysis helps by distinguishing differing requirements at the several levels of action.

Individuals define quality of life differently among themselves, and differently from social goals. Life-systems analysis (LSA) helps distinguish wants and needs. It is appropriate for individuals to satisfy wants to the extent that it can be done without harming other persons or other levels of the life system. LSA also helps recognize that, to a large extent, the widely varying hazards (and costs) of disease are imposed on individuals by chance, even though some choices do influence individual risks of disease. System stability is better achieved by sharing the financial risks universally, rather than in small isolated groups. Further, LSA points to the inevitable limits of individual life, and helps decide the limits of attempts at ineffective interventions.

Society's needs are just as real, but are different. A homeostatic society must reproduce itself and maintain appropriate population levels. Family health for the nurturing of children's health is also a social need, as is the maintaining of the economic and intellectual productive strengths of its members. Society needs to maintain cohesion and avoid the stresses and instabilities inherent in conditions which are perceived to be unjust. These needs are met largely, though not exclusively, through the health care system.

I suggest that this analysis leads us to re-consider 8 a two-tiered health insurance system: A universal coverage level directed toward meeting basic social needs, and an optional coverage level directed toward meeting individual life goals which may exceed social needs.

A UBS program would provide that level of care which is essential for benefit at the social level of the life-system: namely, the general well-being of all of its citizens for social stability and productivity. UBS would include therapies of proven benefit for relief of suffering and for preventive and curative care for all people. These standard benefits would be required to be provided by all companies selling health care insurance, and accepted by all providers of care. Premiums would be paid by whatever mix of employer, personal, and government contributions is required to provide universal coverage. Coverage would be keyed to a no-fault liability system. For UBS-covered services, providers would accept UBS scale benefits as payment in full. Within the UBS program, there would be no benefit distinctions as to age, employment status, income level, or any other consideration.

The OIB program would provide for that care which may benefit individuals, but which does not as directly provide general benefit to society, and which society cannot afford to cost-share if it is to meet its social needs. For example, UBS might exclude any procedure with a less than fifty-percent benefit rate. It might exclude transplantation (perhaps beyond a certain age-limit), extended dialysis, and aggressive therapies of incurable diseases. So long as society can maintain a sustainable reproductive level without them, fertility procedures would be excluded. The OIB program would pay for services not covered by UBS. Payment would be an allowance toward a monitored reasonable fee. Providers could bill for balance due.

Admittedly this leaves a difficult "fuzzy zone" between the two coverages. This category includes procedures with a relatively low success rate and procedures of uncertain benefit. Also difficult to decide would be the extent of care for incurable disease and the extent of rehabilitation measures, when only limited benefit is possible. Initially, these areas would be considered OIB coverage, but as experience and resources warranted, and as benefits of new procedures are proved, some care could be reassigned to UBS coverage. It would be desirable to make a funding and programmatic distinction between normal health care and "attended domiciliary care" for incapacitated persons who do not stand to benefit further from specific health care measures.

Such issues would not be decided individually, however. They would be decided in advance at the national level, by expert commissions appointed for the purpose. The recently-funded Oregon Plan [9] makes such distinctions by prioritizing treatments, then resets limits (for Medicaid coverage) each year on the basis of available funds. The UBS plan would set limits for all patients, using an objective biological standard: the proven benefits of a therapy to individuals with a given diagnosis.

The UBS program must emphasize benefit to individuals, for a system (society) which does not respect its subsystems (individuals) tends toward destabilization. Society derives its benefit through the ready availability to its members of effective health care measures. Yet the program must consider available resources and always seek an equilibrium point between individual and societal needs.

The UBS program does not promise reduction of total health care costs. However, the program would have a helpful effect on costs, by insuring the availability of preventive care, removing incentives for defensive care, promoting proven treatments over those which are merely new, and by offering administrative efficiency. It would require regular funding adjustments to meet its standard of care, for the nation is growing and its lifestyles and distribution of diseases are constantly changing. After all, disease is a life-system concept, too.

It would be essential for public compliance to have full and open discussion and education within society of the philosophical basis for such decisions. Decisions must be based strictly on the objective biological standards, within available resources.

Such decisions inevitably raise concerns about the morality of rationing. Here again, life-systems analysis helps. This proposed system is fair to the same extent that the biological system is fair. Life is fair only in that we are all at risk for disease and death. It is not physicians or other decision-makers in society who choose who lives and who dies. Disease chooses its patients by some inscrutable means, seemingly randomly, without respect to sociological categories. (Even those whose behavior puts them in harm's way are not universally "chosen" for disease.)

The present system "selects" who may be treated by arbitrary sociological categories. The proposed UBS program leaves choice to a "natural selection" process. It uses biological criteria, not social status, as the determining element in access to care. Further, "rational" choices (in two possible senses of the word) are made in advance according to organic considerations of the needs of the whole. The system is designed to reach out to, and respect, all persons. It does not penalize those who wish to provide individually for care beyond the socially-recognized essential level. That is as fair as a living system can be.

The success of our "American experiment" lies in our national constitution's accord with the principle of respect for human persons whose political rights are derived "naturally", and whose governance must incorporate the organic principle of checks and balances. In that sense, life-systems analysis set the foundations of the nation. It has application as well to our search for an equitable system of health care.

Currently there are many proposals on the table for health system restructuring. Inevitably there is overlap of features among them, and with those mentioned here as well. This analysis suggests the strengths of diversity, resiliency and stability which could come from reorganizing the components of the existing system into a homeostatic whole. However, we are unlikely to satisfactorily specify the details of that reorganization until we come to a philosophic consensus which recognizes both individual and social dimensions of existence, in accord with life-systems realities.

No program will long succeed unless it achieves that equilibrium which we know in physiology as homeostasis. If we truly respect life, the principle which guides us in writing prescriptions for our patients will guide us in writing social policy as well.

1. Caring for the Uninsured and Underinsured. (Theme issue, seventeen papers). J Amer Med Assoc. 1991; 265: 2491-2567.

2. Bessinger CD Jr. Living Ethics: Homeostasis and Ethical Principle. J SC Med Assoc, 1990; 86: 631-635.

3. von Bertalanffy L. General System Theory: Foundations, Development, Applications. New York: Braziler, 1968.

4. Engel GL. The Need for a New Medical Model: A challenge for Biomedicine. Science, 1977: 196:129-136.

5. Schweitzer A. Philosophy of Civilization (1923). Reprint, Tallahassee: University Presses of Florida, 1981.

6. Bessinger CD Jr. Doctoring: The philosophic milieu. Southern Med J. 1988; 81: 1158-1162.

7. Manuel BM. Professional Liability -- A No-Fault Solution. New Eng J Med, 1990; 322: 627-631.

8. Korcok M. Can two-tiered health care work? Can Med Assoc J, 1983; 129: 629-635.

9. Hadorn DC. Setting health care priorities in Oregon: Cost-effectieness meets the rule of rescue. J Amer Med Assoc 1991; 265: 2218-2225.

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Essays on Ethics and Healing (index to medical articles, Donivan Bessinger)