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Health Care As Seen Through Closed Eyes

By Dr. Sachin D. Shah

I am in my first year as an attending primary care physician in the U.S.  I have spent the last 9 years of my life learning how to practice medicine by training and working in medically underserved communities in Detroit, New York, and now Chicago.  I’ve likewise spent a significant amount of time the last decade working in the developing world: rural and urban India, Lesotho and South Africa, Haiti and the Dominican Republic, among others.

What I’ve learned is that there is much privilege in the world, but far more poverty; there is fairness for some of us, but for the vast majority there is perpetual injustice.  Inequity is deeply entrenched, not only in places like Africa and India, but also in our own states like Michigan and Illinois.  There is an extraordinary amount of money in health care, especially in our country; yet access to care is too often limited to the privileged. 

Unfortunately, the institutions that benefit from the current system are also deeply entrenched and politically powerful, often determined to preserve a status quo in which they have a marked self interest.  It’s easy to argue for your position from a perch safely overlooking it all.  Meanwhile, vulnerable populations, by and large, remain disenfranchised.  But informed citizens, as recent weeks have shown us around the world, will not long tolerate such institutionalized inequity, especially when it is understood to be a systemic injustice.  Health care should be no exception.

I’m often disheartened by which ideas gain political currency and thus momentum as proposed reforms to our badly broken health care system.  They are usually shortsighted stopgap measures, seen through lenses distorted and opacified by two, four, or six-year election cycles, when fundamental change is most desperately needed.  Meanwhile, attempts to debate admittedly difficult but thoughtful, longer term solutions requiring forthright discussion and political cooperation usually degenerate into polarized partisan propaganda that seeks to vilify those who disagree with your ideology.

When evaluating an idea conceptually (or a present situation practically) I find it useful to apply the concept of the ‘veil of ignorance.’  Stated simply, it assesses the morality of an issue -- like access to health care in our present system -- when reconsidered within a hypothetical scenario.  In this scenario, all societal roles are to be completely redistributed, from behind a ‘veil of ignorance,’ which prevents anyone from seeing to which role they will be assigned beforehand.

To quote John Rawls, whose ‘Theory of Justice’ first described this thought experiment, "no one knows his place in society, his class position or social status; nor does he know his fortune in the distribution of natural assets and abilities, his intelligence and strength, and the like" 

What sort of system would we all agree to in these circumstances?  How would we balance our inherent risk aversion, which favors the construction of a strong social ‘safety net,’ with the inefficiencies that such a system inevitably creates?  The former is our peace of mind should something tragic and unknowable befall us or our family, regardless of our lot in life.  The latter is the basis for the perpetual calls for further privatization, to leave unfettered the invisible hand of the free market.  How loudly would you decry your opponents’ viewpoint on what our health care system should look like without knowing from how high or low a pedestal you will shout?

I’d argue that your language would be more measured, your tone more understanding, if you didn’t know in advance whether you were going to end up a United States Senator or a single mother working full time and relying on WIC for your infant’s formula.  Consider closing your eyes and imagining this next time before opening your mouth and deriding an idea you think you disagree with.


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