Health care debates could use a healthy dose of ideal theory

In early September, the New York Times Upshot published a bold piece titled “The Best Healthcare System in the World.” The article brought together prominent health economists and physician experts to judge the health systems of the world in a head-to-head tourney to determine which health system deserved the prestigious title. The article, published at a time of intense policy debate concerning the U.S. health care system, helped the average American become more educated on how health care operates internationally and what different experts value when judging the successes or failures of a certain system. While it helped answer what the best health care system in the world may be, it ignored an equally important question: what is an ideal health care system?

The tournament in the New York Times article evaluated health-care systems based on familiar measures of success: cost, mortality, readmission rate, and timeliness. These measures of quality evaluate the performance of systems on a clearly quantifiable spectrum. Yet behind these concrete evaluations, lies a diverse set of health care systems, each of which is based on different philosophical interpretations of an ideal health care system. For example, Singapore’s medical savings account program places a high, ideological value on personal responsibility to health, while England’s National Health Service envisions an ideal system as one which promotes equal access. Ideals valued by different countries seem to vary even when their goals are similar. For readers learning about health policy, these interpretations of ideals are not discussed enough. And consequently, their outcomes are even less understood.

To have a serious conversation about outcomes, we must start by talking about the ideal health care system. An ideal health care system is conceived according to ideal theory. Ideal theory envisions the creation of a system in a society which “strictly complies” to the principles it abides by and assumes favorable circumstances that would support the functioning of the system. The concept of ideal/nonideal theory originates from Rawls’ Theory of Justice, a work where he created a widely discussed conception of justice which legitimized the field of contemporary political theory and gave direction to future questions. Ideal theory, in the past, has been overshadowed by work on situations that are less than ideal. As Florencia Luna adeptly argues in Law and Global Health: Current Legal Issues, today’s health care systems are far from achieving “strict compliance” and “favorable circumstances,” and thus the focus should be on amending the nonideal reality that exists today. At the same time, today’s experts are valuing injustices differently according to an unclear set of principles each expert adheres to. There is still broad disagreement concerning larger philosophical questions about health shaping today’s debates about health care systems. Some of these questions include what health is and how is it measured, how much of that health is governed by personal responsibility/choice, how much of that health is the responsibility of the government, and how much variation in health quality is acceptable.

While these disagreements appear heavily centered in theory, their consequences continue to manifest themselves in today’s rapidly changing political landscape. Consider the recently passed tax bill which repeals the ACA’s individual mandate. Norman Daniels argues that this provision lies at the apex of a philosophical debate between the view that health care should be treated as a “modified market” where the market ensures the availability of a basic minimum of care and the view that the most important aspect of universal health care is an individual’s choice to pursue care. In December, the results of the BetterBirth trial which implemented the WHO Safe Childbirth Checklist in clinics in Uttar Pradesh, India demonstrated that while compliance to best practices improved, outcomes did not. The sobering conclusions bring up the debate of whether equity of care can improve health when other social determinants play a larger role.

Ideal theory can step into a more prominent, public role as a tool for framing some of these political debates and providing a central objective behind the measured indicators of a successful health care system. It has already been influential in making a strong conception of health equity. In Public Health, Ethics, and Equity, co-published by Amartya Sen, Sudhir Anand, and Fabienne Peter, Sen employed his previously developed “capability approach” to justice to argue for a more nuanced view of equality in health care which addresses people’s realistic ability to seek out health care taking into account their socioeconomic status, geographic distribution, and their personal choices. The critical acclaim of Sen’s philosophical work led to the development of commissions responsible solely for social determinants of health in organizations like the WHO, CDC, and APHA while also motivating the creation of measures of health which took into account health inequity. Ideal theory can play a similarly normative role in areas outside of health equity by defining the role of health in government and the constraints of health and health care.

These more powerful definitions help experts frame what a just health care system looks like and shape the way current problems are defined. Many experts already wrestle with these philosophical debates internally. But since these ideas about what an ideal system look like play such an important role in how systemic issues are discussed, experts should state the dominating philosophies that inform their evaluation of health care systems. Granted, the Upshot article does disclose the systems which each of the experts prefer, but it would be informative for readers to understand the epistemological source behind which the point of view is founded upon. In health policy especially, there is a substantial theory-policy-practice gap and if experts disclosed the theory which informed their policy diagnoses, it would allow the public to better make their own assessment and to bring in new perspectives.

To the experts who participated in the original tourney, I ask them to publish their own conceptions of an ideal health care system, rationalizing each of their choices, and relating it back to how they ranked the various countries. Dr. Aashish Jha, has already published his own ideal. Not only would it be interesting to compare the ideal systems devised by the various authorities on the American health care system; there would be commonalities which would be apparent when the structure of each system is detailed. And in the divisive landscape of American health care, philosophical agreement gives hope for future policies that demonstrate clearer direction.

Ishaan Shah is a premedical student.

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