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BIOETHICS

Letter from Oxford: Health Care is Not Tyranny

A View of Reform from Across the Pond

U.S. President Harry Truman, British Prime Minister Clement Attlee, and Canadian President William Lyon Mackenzie King. SOURCE: Library and Archives Canada via Wikimedia Commons U.S. President Harry Truman, British Prime Minister Clement Attlee, and Canadian President William Lyon Mackenzie King. Attlee expanded social services in the UK after WWII, including the creation of the National Health Service, still popular after 60 years.

It was sunny and fairly warm when I arrived at Oxford for a conference last Sunday. Even the taxi driver was cheerful as he drove me to Balliol College from the rail station. The off-yellow tint of the great academic structures below their famous spires seemed to glow in the unfamiliar light. But what was on my mind as I strolled around the shopping streets that afternoon, full of chattering young people speaking many languages, was the health care bill. At dinner in one of the ancient pubs that evening I followed the vote on my iPhone, reporting the progress to my American and British conferees. With the time difference I was up late in my spartan college room until final passage.

The next day Oxford weather reverted to form, chilly and damp, but back home the world had changed. British colleagues, while offering congratulations, expressed their usual befuddled amusement at their old colonies’ reluctance to accept the notion of a decent public space. The Brits, of course, are soon to elect a new Parliament, and to the surprise of nearly everyone, the polls show that Labour might retain control, in spite of the massive unpopularity of the Brown government, worries about massive government debt, and a British Air strike ill-timed for Labour.

Even if the Tories pull it off one thing will not change. A couple of decades after Margaret Thatcher the National Health Service remains a popular institution. The welfare state that Churchill claimed was a “Gestapo” in the making is not in jeopardy more than 60 years on (though the tea partiers in the United States could well claim Churchill as their hero). Clement Attlee is not a world historical name, yet as prime minister he consolidated the social democracy that Brits wanted after the War. True, as one colleague observed at yet another pub meal, she was grateful to pay up for a private dentist when she needed a root canal, but no one at the table urged the end of the safety net NHS provides.

I was asked why Americans tend to look to the British way of providing health care when there are so many other models that are in many ways superior. The obvious answer is that we don’t speak French or German enough for them to be viable models, but in truth the Continental systems are both more highly rated for the health outcomes and more technologically advanced than the British. Whether we can “bend the curve” and control the rate at which health costs increase will depend to a great extent on science and technology. Systematic treatment comparisons will need to inform and guide health care decisions, even though outcomes data are often provisional. And the health reform legislation provides for just that in the form of a new institute that will study and compare the effectiveness of different clinical approaches. Information technology might someday improve those results but the platforms available now don’t seem to conform to the way doctors think or practice.

At the end of the day, however, at the current rate of expansion of our ability to intervene in an individual’s medical condition, no country will be able to afford “everything.” The ultimate approach to health care costs must be cultural and moral as well as technical: What do we owe each other?

Unless I have missed other news reports, U.S. conservative cries that the passage of health reform is socialism in the making have not yet turned either the Capitol or the House of Commons into the Kremlin. British democracy remains noisy, full of beans, with a raucous newspaper culture. From the British we can learn that a decent respect for the common good is not a form of tyranny. Perhaps we have taken the first step.

Jonathan D. Moreno, Ph.D., is the David and Lyn Silfen University Professor of Ethics and Professor of Medical Ethics and of the History and Sociology of Science at the University of Pennsylvania, and the Editor-in-Chief of Science Progress.

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