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The Corporate Takeover of the Soul: The Current State of the American Health Care System

David J. Lotto
The Journal of Psychohistory V. 26, N. 2, Fall 1998

My subject for this article is the United States health care system. To paraphrase Dickens, in some ways it is the best system in the world, and in some ways it is the worst. The incredible technological advances in diagnostic imaging, surgical techniques, the capacity to perform organ transplants, and pharmacology, to name just a few, are nothing short of awesome. But the availability of these services to most people is rapidly decreasing. We still have rising costs,1 a steady increase in the number of uninsured and under-insured people, and the large scale acquiescence of the helping and healing professions to the values and ethics of the rich and powerful. We have a health care system which, more than at any time in the past, is governed by the wishes of corporate America.

As a psychohistorian and a psychoanalyst, I am interested in understanding why this is and how it has come to be. As a member of one of the healing professions, I want to deal with my anger and shame about the response of my fellow health care professionals which has been, for the most part, quiet accommodation to the perversion of practice standards which has occurred. As a consumer, I want to speak out about the injustice and stupidity of our present system. As a citizen, I want to act to try to move the system toward humanity and rationality.

There are many possible starting points with which to begin the exploration of this complex area. The one that makes the most sense to me is that of values and ethics. My reason for choosing to focus primarily on this area is that I believe it provides the clearest perspective for highlighting the absurdity, irrationality, and contradictions which pervade our health care system.

The various healing and helping professions physicians, nurses, psychologists, social workers, among others have traditionally held a common set of values and ethics centering on the concept that one's primary professional obligation is to act as a fiduciary for one's patients or clients, that is, to act in their best interests within the domain of one's professional expertise. It is a simple, clear, and admirable aspiration or goal. It has some self-evident corollaries, the most important being in connection with conflict of interest situations.2 However complex and arcane these situations may be, the guiding principle is clear: if there is a conflict, what is in the best interest of the patient comes first.

To be more specific, the helping professional is obligated to advocate for treatment for his or her patient even if it is expensive.3 Acting as a fiduciary for one's patient is incompatible with acting as a fiduciary for the financial interests of one's employer when the employer's primary interest is to limit the costs of providing care. This is the case whether the employer is private or public, for profit or not-for-profit, or even if one is self-employed.

To say it another way, there is an irreconcilable conflict of interest between providing the best care for one's patients, and any form of limitation or denial of care because it is "too expensive."
This is true irrespective of questions of how much we, as a nation, should be spending on health care, what and who we should be spending it on, who gets to make these decisions, and what criteria are used to make them.

Unfortunately, the dominant group belief at this time is that health care is too expensive and that costs must be limited and controlled. It is important to point out that this stance is a political choice, not an economic necessity: 13.8% of GDP is not intrinsically too much. One could well argue that we should be spending more on health care and less on the military and on subsidizing profitable corporations.

It is certainly reasonable to take a position that costs must be controlled, even if this means limiting or rationing care. My point is that there is no way a clinician can perform this function and still act in an ethical manner. The two stances doing what's best for the patient and doing what's best to keep costs down are fundamentally adversarial.

We, as a nation, have a lot of experience in dealing with and resolving adversarial situations. It's what our legal system does. Each side is allowed to advocate for its position and the decision is made by a third party or parties, who are impartial. As recognized by the legal system, only those judges, mediators or juries, who stand to neither gain nor lose financially by the decision and are under no obligation to either party's position, are capable of making an unbiased decision. Thus neither the ethical clinician, who is obligated to advocate for the best treatment for the patient irrespective of cost, nor the managed care corporation, insurance company, or employer who is obligated to maximize profits by minimizing costs, can be trusted to make an unbiased decision.

To show how far things have strayed from the ethics of fiduciary responsibility for patients, consider this from a recent issue of the University of Massachusetts Medical Center Magazine from an article entitled "The Making of Managed Care Doctors:"

It is not enough for medical students to learn medicine. To be successful and effective in today's health care system, medical students must also learn how to manage its delivery. That is, they must mind money as well as medicine.

At U Mass [sic] Medical School, the economics of health care is being taught with as much emphasis, and is considered just as fundamental, as human anatomy instruction."4

This is what they learn in medical school these days.

I also found another gem which I couldn't pass up the opportunity to deconstruct. This is an article entitled The Ethics of Managed Care by Thomas Ebert, MD, Associate Medical Director and Editor-in-Chief of the Clinical Newsletter of Harvard Pilgrim Health Care, one of the largest HMOs in Massachusetts. It is an attempt to construct an argument that ethical medicine can be practiced by managed care.

It is worth spending some time on this because it is an excellent illustration of the sophistry employed by managed care corporations to justify their practices. This article illustrates the rhetorical manipulation the use of euphemisms5 and double-speak (meaning the opposite of what is said), which so often characterize the pronouncements of corporate health care.

Dr. Ebert starts as follows:

Many in the medical profession believe that ethical managed [sic] is an oxymoron, but surely ethical principles can guide managed care organizations. The unique characteristic of managed care is a construct that balances a fiduciary responsibility to an individual and the stewardship of scarce resources.6

Dr. Ebert tells us that "surely," what he wishes to argue for is the case. Thus, by fiat, he decrees that denying care to patients in need is ethical because it is in the service of the "stewardship of scarce resources."

He then says:

There is no socially accepted standard of what constitutes ethical managed care because it may depend on whether people are talking about medical or business ethics.

Business ethics is explained as follows:

All organizations have an obligation to try and stay in business and preserve resources for future use.7

There is a lot of hard work here attempting to blur the clear distinction between a physician's fiduciary responsibility to his patients and a CEO's fiduciary obligation to the stockholders of his corporation. Professional ethics, which means providing the best care possible for patients, is conflated with business practices whose goal is to make money. To call this "preserving resources" rather than what it is, minimizing costs so as to maximize profits, is to use euphemism. To label this as ethical behavior is double-speak.

Now for the psychohistorical part. The biggest losers, the main victims of the present system are, of course, those who are poor and have the misfortune of being in need of health care services. Those who are without health insurance at all and those who are underinsured are the ones who are being deprived of quality health care when they get sick. Those with sufficient financial resources continue to have access to the best in medical care.

This attack on the poor who are sick has much in common with the much broader attack on the disenfranchised that has been in process at least since the start of the Reagan administration in 1981, and has been accelerating more recently. The message and motivation is the same as that which drives "welfare reform" (taking benefits away from welfare recipients) and "getting tough on crime" (making sure criminals are severely punished). Sick people are responsible for their own problems; they are just lazy, stupid, or inadequate, like the welfare cheats and the criminals, not deserving to be taken care of by others. If you can't afford to pay for it yourself that's too bad. No one else, not your employer and not your government, is going to take care of you. A triumph of a cruel economic Darwinism the poor are not fit to receive life giving care; they are not fit to survive. As Howard Stein says:

Managed care is about implicit as well as explicit priorities. It is about people who count and people who are disposable. It is about figuring out ways of excluding people from various kinds of care, and justifying that exclusion.8

As psychohistorians, when we see this kind of scapegoating we want to ask questions about why it might be happening at this particular historical moment. What is the group so anxious, uncomfortable, or guilty about that it has to resort to this kind of attempt at relief? Or alternatively, what trauma has the group suffered that seeks discharge by means of this enactment?

I suggest that the trauma we are attempting to deal with is essentially that of the decline of the middle class which has become the trend-setter with regard to establishing the dominant group fantasy. In the last two decades this group, us, has fallen on hard times. Relative to the expectations established from the end of WW II through the late 1970's, there have been severe disappointments. For one, we have had to give up the belief, or fantasy, of steady upward mobility, in particular the expectation that our children will be economically better off than ourselves. For another, we have lost faith that there will be the security of a steady job, health care, and old age income provided by either our employer or the government. Middle class anxieties are escalating in this time of "downsizing" and "resource limitation;" in Barbara Ehrenreich's phrase, we live with "fear of falling."9 To quote Stein again:

If in the 1960's, the image of abundance and generosity prevailed in political economy, in the 1990's, the image of scarcity and deprivation dominates. There is not enough of anything (resources, money, love, caring, commitment) to go around in order to survive: This is the central, unstated dread of our time.10

As psychoanalytic psychohistorians, we know that this kind of trauma, particularly when its existence is not fully acknowledged, can lead the group into a regression to the paranoid-schizoid position. In this state, that which is felt to be "bad" is split off and externalized onto a scapegoated subgroup which can then be blamed and attacked.

We are in the midst of a time of triumphal capitalism. What's good for the corporation more wealth is what's good for us all. The values of the corporate world, protecting and accumulating wealth, have become far more acceptable than they have been at any time since the gilded age of the robber barons.

It seems that with the demise of the Soviet Union, capitalism has entered into a manic phase. Its values have become glorified and inflated and its flaws are ignored or denied. We no longer have the "evil empire" to satisfy our need for an enemy, or to act as our poison container. As Edward Herman says we have gone from a national security state to a state of national insecurity. There is much searching for who or what might be to blame for our troubles. Who can we focus in on to be our scapegoat and sacrificial victim, whose hardship or demise will magically purify us of our ills and discontents? Unfortunately, with the current triumph of corporate values, we have no shortage of victims; any of our growing population of poor and disenfranchised will do.

These values also facilitate the process of scapegoating. Seeing the poor as fully responsible for their own misfortune is a wonderful defense against acknowledging or experiencing any guilt in relation to the hardships caused to those who are exploited.

The main flaw with this manic capitalism is its blind spot (super-ego lacuna in psychoanalytic language) for denying the widespread exploitation of those on the lower end of the economic spectrum. There is an incredible lack of compassion here. Manic capitalism valorizes cheap labor: it's good for business, keeps costs down, makes things more affordable, increases the total pool of wealth, etc.; but it is deaf and blind to the suffering of those who are providing the cheap labor.

Which brings us finally back to the beginning values and ethics. For me, a health care professional struggling with the realities of managed care on a daily basis, one of the most painful aspects of the current situation is the professions' anemic response to the corporate onslaught against our values and ethics. There are far too many Dr. Eberts among us who are willing to bend, contort, and turn inside out our traditional professional values. Too many are willing to accommodate to the values of the corporate world where protecting the wealth of those who are paying you becomes a legitimate part of your professional function.

Making this kind of accommodation has its rewards, mainly financial security and a comfortable middle class lifestyle. But like all such Faustian bargains, there is a steep price to pay. The problem is that in order to avoid anxiety and guilt we come to share the moral blind spots of our corporate culture. We are in danger of denying our knowledge that protecting the financial interests of our employers will often deprive our patients of something which might well be beneficial, or even life saving.

We may gain financial security and wealth but perhaps only at the cost of losing the soul of our professions the commitment to use our knowledge and skills for the sole purpose of doing what is best for those who entrust their care to us.

David J. Lotto, Ph.D., is a psychoanalyst practicing at 150 North Street, Pittsfield, MA 01201.

footnotes Below

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footnotes:

1. Jan. 13, 1998 Palm Beach Post.
2. See, for example, The American Psychological Association (APA) and National Association of Social Workers (NASW) ethical codes.
3. For example, see the report of The Council on Ethical and Judicial Affairs of the American Medical Association on "Ethical Issues in Managed Care" in the Journal of the American Medical Association (JAMA) Vol. 273, #4, Jan. 25, 1995.
4. Vol. 20, #1, Fall/Winter 1997. U Mass Medical Center Magazine. "The Making of Managed Care Doctors," p.6.
5. See Howard Stein's "The Language of Euphemism and the World of Managed Care," AHEC News, Oklahoma AHEC/Rural Health Projects, Enid, Oklahoma, Nov. 1996.
6. Vol. 1, #6, Aug. 1997. Practice Forum: The Clinical Newsletter of Harvard Pilgrim Health Care. Jewett Lecture: The Ethics of Managed Care, p. 2.
7. Ibid.
8. Stein, op. cit.
9. See Barbara Ehrenreich's Fear of Falling: The Inner Life of the Middle Class. Perennial Library, New York, 1990.
10. "Death Imagery and the Experience of Organizational Downsizing Or, Is Your Name on Schindler's List?" Administration & Society, Vol. 29, #2, May 1997, p.225.

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