“…physicians, as an ethical duty owed to society, must practice efficient, parsimonious, and cost-effective health care.” From The American College of Physicians Ethics Manual, 6th edition.
After 10 days on the Cape, at the Southwest corner of South Africa, 10 days driving thousands of klometers overland on the’wrong’ side of the road and 10 days in Kruger Park at the North East extreme of the country, I hated to leave. Similarities and contrasts between our two nations is evident everywhere: the clash of humanity with nature, cultural present with past, progress with preservation, power with weakness, national language with other languages; all were apparent, even in the relatively sheltered and civilized ‘rest camps’ of Kruger Park. Of course I was at Kruger for the wildlife; perhaps there is nowhere in the world where an English speaking stranger can be sheltered at night in ‘rest camps’- luxurious electric fenced two or five acre cages- yet be free roaming by day in a different sort of cage- a car- while being ignored by herds of wild animals a few feet away. At the same time the visitor is relatively sheltered from political and social conflicts.
Yet even the park exists within the margins of history. The newest and largest rest camp is named ‘Skukuza‘- a native term for broom– because the park founder, Kruger, swept the native peoples from this 19,633 square km area, creating 360 x 40 km park bordered by rivers and by a similar park in Swaziland to the East. The current president, Jacob Zuma, in contrast to Nelson Mandela, epitomizes racial and tribal values. He declares that South Africa is for all (black) Africans; therefore the nation’s borders are now open, by virtue of ethnicity. The park is more affected by poaching; rhinos are affected, though there are so many herds of elephants they must be thinned and exported to other preserves. The Zuma position on open borders is herd politics, supported by a clear majority, who find it justified by inequities or oppression. It was democratically imposed by government, leading to turmoil, as has our Affordable Care Act (ACA), sometimes fearfully referred to as Herd Medicine.
The veterinary medical term “Herd medicine”, when applied to human health care, is disturbing to those who see the ACA in terms of Huxley’s Brave New World , while others find our current “system” antiquated, inefficient, and as unfair as the sweat shops of the Industrial Revolution. I suggest both views are flawed; a dual system is required featuring individually focused care and herd focused care, both are complimentary and necessary in a sustainable national health program. Veterinary medical practice offers a model of such a dual care system where “Herd Medicine” is focused on the greatest benefit to the greatest number, and the economics of health care, while “Companion Animal Medicine” is focused on the benefit to individual animals.
The table below provides side-by-side comparisons between what I will call Herd-Vet ( large population medical care) , and Pet-Vet (Companion Animal) medicine.
•A major factor
•Economic viability/profit critical
•Herd owner pays
•Justified with societal oversight
•Individual pet well-being
determined by vet and pet owner
•Pet owner pays
•Limited/constrained by law
•Abuse is severely punished.
“Pet-vets” practice a type of fee-for-service medical care. The Affordable Care Act (ACA) attempts to retain that kind of care, but requires practicing herd medicine also. These two aspects of national of health care need not be mutually exclusive. Indeed, every nation that has an ongoing viable national health program allows or employs a dual system: one focused on large numbers, outcomes, and economics; and the other focused on outcomes and options for individuals. Both rest on ethical and practical considerations, which address different aspects of national health care.
Where does that leave us in the current medical perfect storm? I confess to optimism. Any objective look at human life on this earth makes clear that over the centuries, people in general have lived progressively longer, healthier, more comfortable lives. I expect our nation will develop a unique U S functional, ethical, and viable system of national health care consistent with both Hippocratic/Oslerian medicine and with the medicine of large numbers, as revealed by the most significant word in the ACA title.
That word is Affordable.
“Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care…The primary function of regulation in health care…is to constrain decentralized individualized decision-making.” From “New Rules” by Troyen A. Brennan and Donald M. Berwick,1995, ISBN-10: 0787901490.
“MDs do not think of…patients as (a) herd (but) future health care decision-makers will.” From “Obama’s Herd Health Program” by Heather McCauley, DVM.
The nation has opted to create some form of universal health care. That is clear.
“…physicians, as an ethical duty owed to society, must practice efficient, parsimonious, and cost-effective health care.” from The American College of Physicians Sixth Edition of its Physicians Ethics Manual
While this statement is reasonable and reasoned with regard to national health care, it is in clear contrast to the time-honored ethical position that ‘Every life is beyond price”.
Though an ambitious endeavor like the creation of national health care is a process, to be revised and restructured as required, strident debates continue. Consider these quotes:
“Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care. . .is to constrain decentralized individualized decision making.” From ‘New Rules” by Troyen A. Brennan and Donald M. Berwick MD MPP
“…the GOD panels (Government Operatives Deliberating) – … which will determine the most cost-effective way to practice medicine, and… distribute rules down to American physicians for deciding who gets what, when and how – tell us that what’s good for the herd is certainly what’s good for the individual.” From the DrRich blogsite January 3rd, 2012 “…
“M.D.s do not think of … patients as (a) herd (but) future health care decision-makers will.” From ‘Obama’s Herd Health Program’ by Heather McCauley DVM
1. a) A group of cattle or other domestic animals of a single kind kept together for a specific purpose.
b) A number of wild animals of one species that remain together as a group:
2. a) A large number of people; a crowd:
b) The multitude of common people regarded as a mass:
I am not a veterinarian. Yet it is reasonable to observe that in general veterinary medical practice is found in two forms:
Herd Medicine -focused on the greatest benefit to the greatest number of animals, and the economics of health care; and ‘Companion Animal Medicine’- fee for service care focused on individuals.
The term herd, when applied to human health care is disturbing to some, who see in it Huxley’s Brave New World; on the other hand, some see in our current medical ‘system’ much of Dickens’ 17th century industrial Britain. I contend that both views are flawed, and that the voting public in general, should realize that these two aspects of health care are not mutually exclusive; they are necessary in a national health program.
The table below provides side-by-side comparisons between herd and companion animal medicine. They are not altogether translatable to human health care, yet they are helpful in considering the implications of the national health care like that of the Affordable Care Act.
Herd-Vet Medicine Pet-Vet (Companion Animal) Medicine
Focus on large populations Focus on individuals
Collective outcome central Individual outcome central
Greatest benefit to greatest number Greatest benefit to the individual pet
Cost /benefit a major factor Cost limiting, but not central
Economic viability/profit critical to all Profit a consideration for ‘providers’.
Herd owner pays Pet owner pays
Decisions based on outcomes , economics Decisions based on emotions and owner resources
Ethical Considerations: Ethical Considerations:
Euthanasia, cloning, etc. justified by economics. End of life and advanced tech decisions by law.
Animal Rights not a prime consideration Animal (‘patient’) Rights of prime importance
Special considerations & legislation Special considerations & legislation
Valuable animals treated as individuals People can be jailed longer for abusing a
Animal rights laws may affect outcomes pet than a person.
In a sense, ‘Pet-vets’ infringed the patent on physician fee for service medical care. (So did hospitals, phone companies, government agencies, and other entities that bill for ‘services’ through a lengthy and unintelligible list of charges; but that’s different essay!)
Society needs now to infringe the patent on veterinary herd medicine, in a dual system to make national health care effective, practical and viable. In fact, dual- herd/individual care- systems have always existed in medicine, like the county hospital/private hospital dichotomy that survived until half a century ago,which was imperfect but functional. In fact, every nation that has a sustainable national health program allows or employs both types of health care: one focused on large numbers, outcomes, and economics, and the other focused on the rights of individuals. Both rest on ethical and practical considerations, which address different aspects of national health care. The ACA is such a duality, theoretically and functionally imperfect but subject to revision and improvement.
Every nation able to offer ongoing universal national health care to all its citizens has found it necessary to develop some sort of ‘two tier system’. Can we do so now in our democracy? We’ll see. I believe we can, and will. Any objective look at the life of people on this earth makes clear that over the centuries, people have lived progressively longer, healthier, more comfortable lives. I predict we will develop a functional, ethical, and affordable national health care consistent with our own culture and history. It will reflect one key word in the Affordable Care Act that implicates features of herd medicine; that word is: Affordable.