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Monday, August 12, 2013

Part 6: What is Choice? (Part 2 of 2)

A Community Conversation About Health and Responsibility: Vaccines and Beyond

Part 6:  What is choice?  (2nd Half)

In the last article, we discussed the reality that there are powerful forces that set the “menu” from which individuals may then make choices.  This isn't necessarily a bad thing, because the human brain can only tolerate so many options before getting overwhelmed.  Our overall goal is the nebulous and elusive concept of “enough choice.”

The first three powerful forces that intersect to control our health care choices are: 
1. Government and Law
2. Official Recommendations
3.  Religion
Note:  Missed last month’s article in The Loop?  
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Now let's get into the fourth major force at play...
4.  Money

The Golden Rule; those with the gold, make the rules.  While we may wish it wasn't so, no group force can sidestep this one.  Money matters in ways both obvious and surprising.  For example, the United States is one of only two nations to allow direct to consumer (DTC) advertising of pharmaceuticals.  Does this empower patients to take control of their own health care?  Or does it allow savvy advertisers to take advantage of vulnerable people?  Profit motives drive health care towards wealthy urban areas and away from poor or rural areas.  This tends to leave certain areas with too much choice (ie: which brand of CAT scanner do you prefer?) and other areas with too little (ie: a 200 mile drive to get a CAT scan).  And, of course, we’re all well-familiar with the complexities, confusions, and frustrations swirling around the issue of insurance!  Keep in mind that personal wealth is not always a liberating force.  A local CAT scan in a rural area cannot be purchased at any price, because the machine just isn’t there.  Conversely, Michael Jackson would most likely be alive today if he had lacked the wealth to buy dangerous, inappropriate health care.  Although, Michael Jackson also might be alive today if it weren’t for...

5.  Social Pressure

Pressure from neighbors, family, schools, and society strongly impacts our health care decisions.  How many of us have used powerful painkillers or stimulants in order to stay on a job despite injury or sleep deprivation?  Social pressure takes many forms.  Organized protest events, such as the ones in front of Planned Parenthood, are often more about social pressure than politics.  When a co-worker is praised for working 16 hour days, it can start to go home at a reasonable hour and get a decent night's sleep.  Or how about the way sports writers idolize athletes who play through an injury?  Or the smile of approval (or scowl of disapproval) from a doctor?  Whatever form it takes, social ostracism generally makes the non-mainstream choice painful, while social affirmation encourages compliance with the norm.  At its best, social pressure can prevent us from making serious mistakes, especially when that social pressure is applied through direct conversations with open-minded and supportive people who have our best interests at heart.  At its worst, social pressure can become a form of community bullying or intimidation.  Both the best and worst aspects of social pressure can happen in groups of any size, from an entire nation to a single friendship.

For a moment, let’s look at a local example of how all five of these forces are intersecting around the Franciscan Health System’s absorption of the Vashon Health Clinic.  As voters and citizens, we have participated in the process which led to the current menu of legal medical procedures, rights, and freedoms.  As islanders, we sought cooperation with the government (tax dollars), and Grannie’s Attic was created to help with ongoing funding.  Even the decision to partner with Highline was driven by economics.  Then, as Highline faced tough economic times, some form of official recommendations were sought and received, leading Highline to consider a merger with the Catholic Franciscan Health System.  This merger was born of economic need and has brought with it both a blend of economic support for ongoing services and religious-based limitations of available medical procedures and freedoms.  In response, we see social pressure in the form of community meetings, articles in the local papers, letters to the editor, invitations to consider the Catholic viewpoint, and activism as concerned islanders begin to search for a different, 3rd option.  That option, of course, will also be impacted by all five of the major menu-setting forces.  And so it goes.

The five forces of law, official recommendations, religion, money, and social pressure all work together to set our health care menu.  Now, let’s review their unique strengths and weaknesses.

Law is often slow and clumsy.  It is the only force that can apply criminal sanctions, although religions can excommunicate you.  However, it is also the only force that offers a guaranteed opportunity and clear process to
challenge an existing decision.

Official recommendations can change rapidly, but this agility also makes them vulnerable to trends, poor research, and short-term thinking.

Religion can offer genuine concern for the large picture of human society, but it can be almost impossible to challenge a religious doctrine successfully.  In addition, personal religious beliefs of equal value can occur in absolute opposition to each other.

Money can open many possibilities, but self-interest and greed is ever- present.  Once set in place, changing the flow of money can be extremely difficult.

Social pressure can be the most flexible and individualized force, but its nebulous nature makes challenges difficult.  Pushing back against social pressure can feel like fighting clouds; you can't get a grip on them, they won't go away, and then they suddenly clear up for no apparent reason.

As with all of life, diversity is strength.  It will not serve us well to live with a medical menu that is set only by law, or official recommendations, or religion, or money, or social pressure.  We need a balance.  And when that balance is disrupted, we need to push back until balance is restored.

“A Community Conversation About Health and Responsibility: Vaccines and Beyond” is an ongoing series written by two close friends with a passion for improving community cohesion and building respectful relationships in a diverse world.  This article was co-created by Karen Crisalli Winter and March Twisdale.   BLOG:   Email:

Part 6: What is Choice (Part 1 of 2)

A Community Conversation About Health and Responsibility: Vaccines and Beyond

Part 6:  What is choice?

Society is, by definition, a collaboration.  Like all group environments, there is a give and take of rights, responsibilities, and choices.  This is true whether we’re talking about a family, a town, a board, or a hospital.  This is also true whether you live in a democracy, a theocracy, or a tyranny.  In all systems, there are forces that "set the menu” from which individuals can then make a choice.

Despite the rhetoric to the contrary, limitations can be a good thing.  The human brain can only tolerate so many options before getting overwhelmed.  When overwhelmed, our ability to choose well goes down dramatically...a known fact that is sometimes used against us in aggressive and unscrupulous marketing strategies.  At other times, however, a plethora of choices is valuable.  For example, few people need every single brand of detergent to be offered at their local store.  Even fewer wish to spend hours in the soap aisle carefully weighing the advantages and disadvantages of each product.  On the other hand, people with severe skin allergies might be very interested in a wide selection of detergents; as they hope to find one that won’t give them a rash! 

In general, a collaborative society seeks to meet the needs of the community and the individual by setting a menu of options that is not too narrow and not too broad.  Most of us, consciously or unconsciously, believe that the best way to ensure “enough choice” would be to have someone like ourselves be in the “menu selecting” position of power.   However, when the menu is set by people whose values differ significantly from our own, we tend to express considerable outrage!  This leads to a great deal of amusing and ironic hypocrisy from all points on the political compass.

When speaking about public health, there are a variety of forces that overlap, conflict, combine, and collaborate to create the menu of health care choices available to individuals.  In this article and the next, we'll look at five of the most powerful group forces at play, and our access as citizens to these arenas of power.

1.  Law & Government
Our society decided long ago that legal oversight of choice is desirable.  However, where to draw the line is often a contentious question, leading to spirited debates.  This is further complicated by the fact that our government was designed to spread “menu control” around, with the federal, state, county, and local layers of governance each having limited, intersecting, and sometimes conflicting powers.  For example, the civil rights movement, marijuana legalization, and the recognition of gay marriage are all interesting areas of tension between state governance and federal governance.

When it comes to our access as citizens, some laws are passed with great fanfare, others are passed very quietly.  But, all laws in this culture are documented and there are established methods for individuals to work toward altering them.  However, just because a choice is legal does not mean it is available.  There are many other forces that limit availability like....

2. Official recommendations
Various governmental and professional groups make official recommendations.  These groups are obligated to follow the law and their recommendations are documented.  However, there is often no clear path to challenge recommendations, even though they may limit medical choice just as effectively as law.

Consider the 2008 recommendation by the American College of Obstetricians and Gynecologists (ACOG) on the subject of vaginal birth after cesarean (VBAC).  The 2008 recommendation stated that a VBAC should only be attempted if a surgical team was “immediately available."  This recommendation led to many resource-limited small or rural hospitals refusing to permit VBAC due to lack of an "immediately available" surgical team.  Thousands of women were forced into expensive and potentially dangerous surgeries they did not need and did not want.

Now, consider the education of your family doctor.  The Accreditation Council for Graduate Medical Education (ACGME) is a private professional organization responsible for the accreditation of 9,000+ residency programs.  Residency programs currently include training in all forms of legal birth control.  However, accreditation requirements are reviewed every seven years, and that review is happening now!  Will the requirement for training in birth control be weakened or eliminated entirely?  The Catholic Ethical and Religious Directives expressly forbid contraceptives, leaving 30-50% of US hospitals unable to offer a “full education” residency program due to restrictions from...

3.  Religion

The separation of church and state both protects our secular society from becoming a theocracy and allows religious groups to follow their faith with autonomy from popular opinion.  This autonomy even allows religious groups to defy certain laws with relative impunity.   A church can refuse interracial marriage, so long as it is willing to forego the tax benefits of being in compliance with federal civil rights law.  The “sanctuary movement” of the 1980's consisted of churches openly defying immigration laws to provide sanctuary for Central American refugees fleeing civil war.  Religious exemptions from vaccination laws are respected in nearly all states.

This independence gives religion unique power when setting the public health “menu.”  Historically, a variety of religious groups have sought to expand, restrict, or modify the health care menu.  One strategy is religiously-based political action.  Another strategy is social pressure, which we'll discuss later.  Yet another strategy is the ownership of medical facilities, which are then obligated to follow the religious values of the sponsoring religious organization. 

Religiously controlled health care mostly becomes problematic when a single religious group controls such a large percentage of medical facilities that it begins to function as a monopoly.  Monopolies of all kinds interfere with individual choice, thus the various legal restrictions upon them.  A religious monopoly upon a vital service like health care has some very serious implications.  The carefully crafted checks and balances of our political system do not apply to religious organizations, leaving the individual very few medical or religious rights that can be defended.  Thus a religious monopoly can endanger both our health care and our religious freedom.

So why would anyone accept a religious monopoly on health care?  In general, it’s all about....

4. Money

Which is what we'll start talking about next article.  See you then!

“A Community Conversation About Health and Responsibility: Vaccines and Beyond” is an ongoing series written by two close friends with a passion for improving community cohesion and building respectful relationships in a diverse world.  This article was co-created by Karen Crisalli Winter and March Twisdale.   BLOG:   Email: