What’s the point of health care? Does that seem like a question with an obvious answer? It would be reasonable to expect that the answer would be that health care is about caring for people’s health. But that’s an answer which is not really an answer. It raises the question, what is health? Stop and think about this for a moment, because it’s not a straightforward question to answer. My answer is that health is a phenomenon in its own right – it is NOT the mere absence of disease. It has distinct characteristics – adaptability, creativity and engagement. Others will have other answers, other characteristics to add, other qualities. It’s difficult to extricate health from the old concept of “eudaimonia” which tends to be translated as “happiness”, or even “wellbeing”, but I prefer the word “flourishing”. Surely health is about flourishing? The less we flourish, the less we rate ourselves as being healthy, well, or good.
This way of thinking about health is holistic. It demands that we consider the whole of a person’s life, and by that I mean the whole of their present time life (a biopsychosocial approach), and the whole of their life from start to finish. This has at least two consequences. Firstly, it means that all health care must take into consideration, not just objective disease in the form of pathology or lesions, but it must consider the individual patient’s story. No two patients have the same life, and therefore, no two patients share the same experience. With the same disease, two people will experience different symptoms and those symptoms will mean something different to each of them. In addition, each individual will have their own ways of coping, adapting to and dealing with their illness. Health care needs to relevant to the individual who is being cared for.
Secondly, it means that health care interventions will alter the experience and course of a person’s life, but they do not, ultimately, prevent death. The overall mortality for human beings is 100%. We do all die. But much of contemporary health care is predicated on the basis of death avoidance. We are bombarded with claims about “life-saving” medicines and Public Health policies which claim to reduce death rates. Statins, for example, are even promoted for healthy people, to reduce their risk of death from heart attacks and strokes. Whilst nobody would really like to have a heart attack or a stroke, no-one is asking the question, what do people who would have died from a heart attack or a stroke die from instead? The focus is on death avoidance. People are classed as being “at risk” – at risk of dying from disease x. But to make an informed choice about a treatment don’t you need to have an idea of the possible and likely consequences of that treatment? To say a treatment reduces your risk of dying from disease x is all very well, but it doesn’t say much about whether or not you’ll experience a life of greater flourishing. Especially if you develop another more disabling, painful condition instead. The logical extension of this death avoidance thinking is to try to avoid death from all causes. For example, some doctors and scientists have promoted what they call the “polypill” – a combination of drugs all in one pill, which, if taken by the whole population (or in this case the whole population over the age of 50), would significantly reduce the death rate from cardiovascular disease. Well, if you don’t die from cardiovascular disease, what do you die from? Cancer? Nervous system disease? Liver disease? Blood diseases? There’s no way to know of course but isn’t it true that it will be something else? Or do you think healthy people die disease-free?
It’s likely that a person will fight hard for life at all times. (Well, not everyone, as Dylan Thomas wrote, “Do not go gentle into that dark night. Rage, rage against the dying of the light.” exhorting his father to fight for life at the end of his life). Around a third of all health care expenditure is on people in the last year of their lives. (see New England Journal of Medicine 1993:328:1092-6 for example) You might hope to live three score years and ten, and if you do, you can expect that most health care you receive will be in your last year of life. Think of it this way – assuming 70 years of life (I know, that’s quite an assumption!), one third of your health care will be in one seventieth of your life and two thirds for the other sixty-nine seventieths. Why is that? Because you can expect to flourish for 69 years and suffer for one? I’m not sure that’s most peoples’ experience. If health care is about improving life as opposed to merely trying to avoid death why don’t we direct more of it to life instead of death avoidance?
It seems that our so-called “health care” isn’t focussed on health at all. It’s focussed on death avoidance. That was the goal of the alchemists – the elixir of life which would produce immortality. But that’s a myth isn’t it? Shouldn’t we have health care which is more realistic? After all, if we do address illness holistically, reducing suffering, encouraging healing, resilience and growth, aren’t we likely to also increase the length of life? Might that not be a better way to avoid “premature deaths”?
Maybe we should be concentrating on increasing health, in a eudaimonic sense, instead of concentrating on avoiding death, which, realistically, is ultimately impossible.
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