Missing in Health Care: Common Sense

When I was a boy of roughly 10 or 11, I came across a phrase spoken by teachers and other similar role-modeling adults that baffled me: common sense. It's only now, decades later, that the undefinable, ineffable "common sense" rears up its head again, this time to cover everything that's missing in U.S. health care -- not to mention the debate about its reform.

Let me paint a picture that is a composite of several experiences, my own and those of others.

You go to a doctor because you feel pain -- or a growth, or something that makes you feel uncomfortable about the state of your health, all of which, in the end, is pain. Yet the first thing that happens when you present yourself at a place designated to dispense healing is you get barraged with questions which you are usually in no mood to answer, or if you are, often cannot quite come up with one. Why? Because you are in pain.

I once tried yelling out "I am in pain." No one moved, everything proceeded as usual. So, you're in pain but they're there first and foremost to CYA and M-I-C-K-E-Y M-O-U-S-E you to death.

You're not important. The doctors are important; if not the doctors, then the stockholders, the managers or their aunts in Timbuctu -- anyone but you. Their time is money and their employees know better than to waste it. In this economy finding a new job is tough.

Assume you get treatment before your great grandchildren go to college -- a big assumption in most emergency rooms. Seriously ... the only time I ever got immediate assistance was when I literally collapsed on the desk of the receiving nurse.

Then they ask you what is wrong with you, yet saying "X hurts" -- where X is the part you are clutching like you'll fall into the Grand Canyon if you let go -- is never good enough. They want "I have an episomataspermoanthrodosis that has just trifulcated endomatically." What is wrong with these people? Do you look like you went to Harvard Medical School?

Then come forms of torture that the Inquisition abandoned sometime in the 1840s -- called "tests" -- to determine why that severed foot is bleeding. "Aha, your foot is disconnected from your leg hence the blood vessels have nowhere to go and the blood ... "

They can't say that. So they invent something that sounds good. Shrinks diagnose anything they don't really know what it is as "borderline." Physicians call anything to do with skin "dermatitis" (essentially skin+itis). Borderline dermatitis should just about cover anything.

There's a whole slew of scientific sounding terms for "Hmm ... I don't know what the hell is wrong with you, but since I'm going to charge you at least a few hundred dollars, I might as well make up something." If you don't know what the term means and they can't explain it in simple terms, you've got that Don'tknowwhatitis Syndrome.

Then you don't quite trust what they say, in part because no doctors look like Marcus Welby any more. Did they ever? I mean, Welby was a TV character. Old doctors can't afford the litigation insurance, young Welby-like people are making money on Wall Street securitizing insurance against unknown diseases, or starring in TV shows.

The doctors can never be bothered to explain anything from a normal person's perspective. Nurses dig into your duodenum while they chirp happily, "how are we feeling today?"

Everybody robotically follows some list of tasks written up by the MBA who runs everything from an office tower in Chicago. Even nurse cheer, probably quantified under Baldridge Criteria for Performance Excellence, is prescribed precisely.

U.S. health care, after all, is designed to imitate the assembly line of a Ford Model T automobile. Put an insured patient with the proper documentation at one end and spew out a much poorer, somewhat healed, not healed at all or even dead person, at the other end. All very efficiently, you understand.

If you're tempted to say it's the profit motive -- which in part it is -- you're missing the entire point. Profit is part of the problem, but it's not the essential problem.

The basic problem is a deficit of common sense.

That's a social problem. As we develop into an ever more individualistic society, we are losing our sense of commonality and the ability to trust in our own judgment as adults. That's what common sense was.

"Common sense," growled by exasperated teachers and adults, was what we children lacked when we did something dangerous or foolish or simply without thought. We failed to rely on the accumulated social wisdom concerning some basic basics.

Patients must be ask what they are allergic to, because that way, if we goof, it's their fault. Medical people can't trust their senses because they will be sued. Besides, they make more money testing.

It's a bother to apprentice and train people to use some horse sense about the degree of cheeriness a patient can take while you are rearranging the duodenum; so just give them a clipboard and a checklist: "Item 7: rearrange duodenum while proffering a toothy smile and Baldridge level 4.7 cheer."

The common sense of what is really needed to apply a modest amount of healing -- pain, after all is what keeps us alive -- has gone out the window.

Delusions and Consequences

Is it your fault if a relative you drove to a hospital doesn't like your choice of venue or somehow gets sicker, even though you didn't choose the equivalent of a refugee camp clinic in Chad over a peer of the Mayo Clinic? You had two apples, a red delicious and a granny smith and with the best intentions you chose one over the other.

Is it your moral, philosophical or psychological fault if the person you gave the apple to gets an indigestion or just plain doesn't like the taste? There are people -- often enough they are women taught to apologize for their mere existence -- who would beat themselves up, who would engage for hours in exploration of the chain events that any small and largely apparent choice brings on.

You decided to major in English literature and not accounting, so you failed as a novelist and live in a garret in East St. Louis, but your accounting-major classmates have already retired to mansions in Provence. You turned left rather than right at a certain intersection and a truck laden with hundreds of pounds of bananas backed into your car three blocks later.

Remember, we're not talking legal here. Lawyers could argue that a matricidal maniac should not be punished harshly because he is an orphan, but that's not the kind of issue on which I want to dwell.

Responsibility, to my mind, turns on whether we actually have choices. I would argue that most of us have extremely few meaningful choices and it's a delusion of grandeur -- or Calvinism, depending on your mileage -- to think otherwise.

If I were given the choice of being 15 again to relive it all, given what I know now, I would like to think I would make choices that would make me either rich as Donald Trump or famous as Albert Schweitzer or, at a minimum, irresistibly handsome to women ranging from Heidi Klum to Janet Reno. But it's just not so.

Let's take Heidi Kulm and Janet Reno. Attractiveness to the opposite sex is based on a wide range of biological factors that pair certain groups of men and women with each other and the results ... are happenstance. An actress once told George Bernard Shaw that if they had a child it would be beautiful and brilliant, only to hear from Shaw that the reverse would be true if the child inherited her brains and his beauty.

Social norms have tended to accentuate some aspects over another. Indeed, in its pursuit of study, the Jewish tradition has historically pushed its most intelligent people to marry. A rabbi's son was once the dream husband. Conversely, the rule of priestly celibacy in Catholicism assured that, at least during the long medieval night, the era's most educated and talented men of western Europe either did not reproduce or spawned children born into social disadvantage.

I belabor birth, because one's birthplace and parentage remain the most meaningful and decisive factors in lifetime social and economic outcomes -- democracy and everyting else notwithstanding. Unlike many Americans, I did not get to choose mine, which is why I am not particularly proud of being American -- or of occupying a given quintile in U.S. income distribution or hailing anciently from a particular corner of the world.

It's simply not true that being superior makes you white or being smart makes you rich or being chosen by Uncle Sam makes you number one. Even if it were, what did you have to do with any of those?

So what makes you think that you had a real choice in the hospital for your relative? You didn't have a choice between the Chad and Mayo clinics. At worst you had a choice between equally mediocre hospitals operating in the midst of a collapsing system.

We all do our best -- and, yes, we can choose not to -- and consequences spring whether we like them or not. I'm not even sure that doing one's best makes a difference, except to ourselves.

Values vs. Interests

Dinner with a friend occasionally allows one to plunge into the foundational philosophical issues, disregarding the day's din. In this case, it was the longstanding discussion between materialism and metaphysics -- although he protested that it was not. The crucible in which these views were tested was the basis for human conduct, social convention, law.

My friend held to the traditional, majoritarian view that humans respond to certain essential values that they develop or absorb from childhood on. In other words, we have a nonmaterial, psychological machine, so to speak, that processes certain thoughts and yields certain abstractions called ideas -- in this case they are ideas about what ought to be done.

The ancient Hebrews asked for a king anointed by God and the Romans claimed the Emperor was divine, hence ordained to rule.

Bossuet, court clergyman to Louis XIV, christianized the idea with his theory of the divine right of kings. This echoed Charlemagne's own ecclesiastical scholar court jester, Alcuin of York, who argued that "the riotousness of the crowd is always very close to madness."

Alcuin, I'd guess, would have seen his opinion confirmed in this summer's town halls.

It took 13 centuries for a very chastened Christianity, in the voices of Jacques Maritain and the postwar Christian Democratic parties of western Europe, to adopt democracy, under the motto vox populi, vox Dei (the voice of the people is the voice of God). Too late; that was two centuries after the seizure of the Bastille.

Not only has power traditionally been seen as flowing from godhead to crown and scepter, but also to all morals, laws, socially sanctioned customs and so forth. Or, among philosophers in a theist ocean, ideas spring from the psyche and its archetypes, whence spring philosophies, legal systems and the ordering of what Hegel called "civil society."

Karl Marx was not the first one to dethrone this idea, but he was among the most articulate of early, rationalist critics. In a view he summarized in the much-debated 1858 Preface to his A Contribution to the Critique of Political Economy, he wrote:

In the social production of their life, men enter into definite relations that are indispensable and independent of their will, relations of production which correspond to a definite stage of development of their material productive forces. The sum total of these relations of production constitutes the economic structure of society, the real foundation, on which rises a legal and political superstructure and to which correspond definite forms of social consciousness.

These words, which essentially state that the struggle for survival is the basis for everything deemed holy and sacrosanct, or at least, legal and enshrined by custom, struck me like lightening when I belatedly first came across them, while working, oddity of oddities, for the U.S. Catholic bishops, several decades ago. Until then, I had been a modern Thomist.

I never came to embrace the mechanistic view of historical materialism as expressed by the Leninist parties, but I will freely admit that my more recent, post-Christian ethic of survival bears some debt to old Karli.

The fundamental human striving is to survive. As a friend undergoing cancer treatment reminded me recently, we live pretty much like the man who, having flung himself from the top of a tower of Notre Dame, thinks to himself as he falls, "I hope this lasts a while."

To my mind, having rejected the existence of a soul, the metaphysical or spiritual world, all of which puts the existence of any god into serious doubt, it no longer seems plausible that a reality other than the material actually exists.

We have material interests, sure. We canonize these interests in our customs, our laws, even our religions and philosophies. But we do not have values founded in any "higher," nonmaterial source, simply because such a source does not exist.