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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?  
Check it out on our blog:

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:

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Welcome to the conversation. Knowledge changes. People respond best when this truism is kept in mind. In community, March & Karen