A Couple of Limits-related Conversations

Excerpted from the Creative Systems Theory manuscript.

Bill (a physician):  I have a health care question.

CJ:       Sure.

Bill:     What kind of health care delivery system do you think makes most sense?  A free-market, fee for service approach like we’ve had?  A single payer, more centralized approach? I’m now part of a managed care system. People assumed managed care would increase quality of care and reduce costs. But today I have much less time to spend with each patient than I did ten years ago, and costs have not stopped rising.

CJ:       I know few more complex and entangling dilemmas than health care delivery. Health care expenditures are spiraling uncontrollably with no natural end in sight.

Escalating costs are nobody’s fault. They are a product primarily of modern medicine’s great success. Early innovations—like sterile technique and penicillin—were relatively cheap. More recent advances—sophisticated diagnostic procedures, exotic new medications, transplant surgeries, and more—are increasingly expensive and promise only to get more so. But while blame accomplishes little, if nothing changes we face real problems. Somehow we must do things differently.

Bill:  And the kind of managed care I’ve been involved with as a solution?

CJ:  Managed care provides some benefits, but as far as addressing cost-containment’s underlying dilemma, it doesn’t, by itself, do any better than the old physician-centered model. It has been a stopgap measure at best. People hoped that putting decisions in the hands of a third party would reduce costs by eliminating inefficiencies and the most obvious of unnecessary procedures. Short term it often did. But, predictably, costs again have risen and vulnerable populations again put at risk.

Bill:     What are we missing?

CJ:       A fact that should be obvious, but which stretches us so fundamentally that we do our best to keep it “out of sight and out of mind.” Unless we are willing to spend an ever-expanding percentage of national resources on health, we have no choice but to put limits on health care spending.

Initially that means cutting back on procedures that do not have proven benefit. Studies suggest that one third of health care expenditures relate to serves that don’t really help and may ultimately do harm. But while greater attention to efficacy will help, it can’t be enough. Eventually, too, we must be willing to restrict care that may benefit, but which is simply too expensive.

That means confronting the dreaded “r” word—I’ll say it, rationing. We have to limit available medical services. While we’ve effectively rationed care in the U.S. by making it difficult for people who can’t afford care to get it, rationing care in the sense of making the conscious choice to limit treatment is something new—and understandably unsettling to contemplate.

But there is no other option. To deny this fact is simply to have our heads in the sand. It is also to waste our time developing policies that cannot ultimately work. In the current health care debate, neither the Left nor the Right has provided the necessary leadership. The Left claims that what it puts forward won’t result in the limiting of care—and unfortunately they are correct. The Right uses the word rationing as a condemning epithet. Both positions not only leave us short of useful answers, they ignore the hard and necessary questions.

Bill:  Hmm.

CJ:        It might seem strange that we could miss such an obvious reality. A high school student could do the numbers.  But in fact it is not strange.  Effectively confronting health care limits presents a whole new order of moral challenge. Not providing care when we have effective care to offer at least calls into question modern medicine’s defeat-disease-at-any-cost heroic mythology. But that is only a beginning. Rationing care demands a new relationship with life’s ultimate limit—with death.

Medicine has always been about life and death decisions. But limiting care demands in effect the conscious choosing of death. Withholding care that might delay death’s arrival is different only in name. Limiting care requires a maturity in our relationship with death that was not before necessary, nor, I would argue, within our human capacity to handle.

We’ve before chosen death for others in a more limited sense. But in times past, the “others” have always been people fundamentally different from ourselves, such as enemies and criminals. Imbedded in our cultural mores has been the assumption—I think accurate—that anything else risked starting down a slippery slope that we likely could not manage (as with Nazi death camp atrocities performed in the name of medical research).

Bill:     What you suggest violates the Hippocratic Oath.

CJ:       In a sense it does. At least it requires that we expand “do no harm” to include the health of communities and societies as well as individuals.

Bill:     I couldn’t accept that.

CJ:       I don’t think you have a choice. The question, long-term, is not whether we will limit care, but only how we will do it—how consciously we engage the task, and how fairly we go about making the tough decisions the task requires.

Bill:     That is a messier picture.

CJ:       Certainly a more limits-accepting, systemic picture.

Bill:     I wonder if the extreme rancor in the current health care debate isn’t a product of what you are talking about. Health care policy would seem a pretty boring topic, hardly controversial enough justify the name calling we’ve seen.

CJ:       I suspect that is right. We should expect rationing care to trigger the same emotions as more circumscribed death-related controversies like abortion, capital punishment, and assisted suicide. Before we are done, it will likely make them look like child’s play.

Bill:     If we have to limit care, decisions should not be made by insurance companies.

CJ:       I totally agree. The arrangement is ultimately unworkable for everyone—patients, the medical profession, and perhaps most of all for the insurance companies. Insurance companies will find themselves in the crosshairs of increasingly intractable controversy—and facing ever-diminishing profits. Replacing the medieval guild-like model of traditional health care with a more explicitly economic model is ultimately unworkable not just because it ignores economic limits. More deeply it ignores that health care concerns, because they involve the lives of human beings, are moral as well as monetary. Today this means moral not just in the sense of right and wrong, but in the complexly multi-layered sense shared by all emerging moral dilemmas.

Bill:  Do you think a single payer approach would be best?

CJ:       I suspect a variety of approaches could be made to work. The issue is not what delivery structures we choose, but our willingness to confront fundamental limits. If we let our fears of acknowledging limits win out,  confusion and suffering will be the result whatever policies we enact.

A single payer approach could help us face the hard decisions more efficiently and fairly, but it doesn’t guarantee the courage to make such decisions. And a single payer approach has its own limitations. For example, a one-size-fits-all system can thwart innovation. Innovation is difficult without diversity in approach. I suspect different countries and locales will choose differently. But, whatever approach we use, the key lies with the emotional maturity the hard choices will require.

Bill:  It won’t be easy.

CJ:       Not at all. But the rewards go beyond just more effective health care delivery.  Confronting limits should contribute also to a more mature, creative, and empowered pictures of health care more generally. Start addressing health care limits and pretty soon we begin examining questions that expand the health-care picture dramatically. For example, we might ask  “Wouldn’t it make sense to spend more of our money on prevention?” And then, “If prenatal care is valuable prevention, what about good nutrition, and if good nutrition is important what about cleaning up toxic chemicals in the environment, and if that is part of it too, what about the effects of poverty, and lack of housing, and …. today’s crisis of purpose and hope?” That perhaps takes the systemic analysis too far, but you get my point.  Acknowledging economic limits leads ultimately to rethinking fundamentally. And for today that is  “just what the doctor ordered,” a fresh, really big-picture look at the whole health care endeavor.


Beth (an environmental activist): I work protecting salmon. We humans have got to accept that we can’t continue to do all sorts of things that in the past we’ve done as a matter of course. The planet just can’t endure the effects we are having on it.

CJ:       I totally agree. Is there a question there?

Beth:  I was just wondering how protecting the environment fits into the concept of Cultural Maturity.

CJ:       Facing the fact of environmental limits is an essential part of humanity’s needed growing up. You don’t need to hear the sermon. Our current unwillingness to make the environment a priority threatens to turn the world into a most unpleasant and unhealthy place to live—for all its inhabitants. For a rapidly increasing number of the world’s species, it turns it into an impossible place to live. And we are not immune from the threat. However clever we may be, nature bats last.

Beth:  How do we get people to wake up? I guess part of it is just time. People will support good environmental policy when they experience more directly the effects of our shortsightedness. But by then, for so much of what people like myself are trying to protect, it will be too late. I find it all very sad and frustrating.

CJ:       I share your frustration.

Beth:  Do you have any advice for the environmental community? Do you see ways that environmental efforts could be more effective?

CJ:  A few thoughts.  But they require accepting truths that environmentalists themselves tend not to want to look at. They also involve limits, just of different sorts.

Beth:  Okay. Go ahead. I’m ready.

CJ:       A first piece concerns limits to what even our best efforts can accomplish. You work with salmon. I had a conversation recently with a friend who is helping to coordinate Puget Sound salmon restoration. I asked him what most often got in the way of good policy. His answer left me feeling like I had been hit in the stomach.

Beth:  Which was?

CJ:       Our taboo against admitting how little we can sometimes do at this point to make things different. Even if we give salmon restoration top priority, he claimed, the best we can hope for in Puget Sound twenty years from now is a couple of showcase native salmon runs and five or six solid hatchery runs. And if we make salmon too much of a priority, we ignore other species that, while less symbolic, are just as important. Who knows how accurate his numbers will prove to be. But he is on target with his claim that ignoring limits to what is likely possible can result in funds being spent unwisely and ultimately counterproductive policies.

Beth:  You are right.  I didn’t want to hear that.  Do you have more glad tidings?

CJ:       Sure—environmentalists have to face limits to the continued effectiveness of familiar rallying cries. Even the best of environmental thinking has tended to be polar—and often polarizing. It has set political left against political right, environment against business, and, at its extreme, nature against humanity. I’m not critical of this. In the past, ideological passions were often exactly what was needed to get people to pay attention and to motivate action (and sometimes still are). But they are becoming much less helpful. The most forward thinking environmentalists have set aside ready dogmatisms. Increasingly, successful advocacy demands it.

Beth:  So we can get diverse constituencies on board.

CJ:    That’s part of it. Good environmental policy almost always requires the involvement of multiple stakeholders. But, as much, it is so the policies we craft will in fact benefit us. Proposals that are not sufficiently systemic can point us toward ends that can’t be achieved—or worse, that we wouldn’t want to achieve. I’m not at all suggesting that good policy means always finding some middle ground between competing desires.  Frequently extreme policies are called for—the solution to the disappearance of old growth forest is not to cut down half the trees. I am saying that effective policy requires that we appreciate the big picture, not just our favorite parts of it.

Beth:  There are ideological traps.

CJ:       Exactly. And they get in the way not just when we disagree on what we should try to accomplish, but also when deciding what to do when we agree. A great place to see ideological traps is to notice people’s initial responses upon hearing advocacy for technology-based approaches:  bioengineering as an answer to food shortages, nuclear power as an energy solution, or technical fixes as antidotes to rising greenhouse gas levels  (as in the suggestion that spraying sulfur dioxide into the atmosphere might provide benefit). I’m not voting one way or the other on any of these methods, just pointing out how often our responses are ideology-based. More “left-hand” sorts tend to reflexively oppose them; more ”right-hand” types tend to immediately celebrate them. We need instead to consider all our options and to carefully evaluate each of them in terms of possible benefits, obvious dangers, and potential unintended consequences.

Beth:  We have to be okay with a more complex reality.

CJ:       And what can often feel like a less sexy reality. But policy that is pragmatic—in the sense of being systemically conceived—not only results in better buy-in and better decisions, it also helps people avoid cynicism and burnout by focusing their attention on things that can be done and should be done. Arguably, in the end, that is even more sexy.

Beth:   I’d like to take our conversation off on a bit of a tangent if you don’t mind. What you say suggests something beyond just intelligent policy. You seem to imply a different way of relating to nature—and thinking about what nature is. Is that right?

CJ:       Great observation. And I don’t consider it a tangent. Thinking about nature in new ways will be essential to going forward. In modern time we’ve tended to view nature from one of two polar vantages. We’ve treated man as distinct from nature with appropriate dominion over her. Or we’ve romanticized nature, as is more common in environmental circles. Each view has problems. The difficulties with the first are obvious. Overestimating our ability to control nature leads to naive and dangerous choices. But the second can just as readily result in unworkable policy. If it doesn’t outright demonize humanity’s influence, it minimizes the importance of human well-being in the ecological picture. Acknowledging limits to past ways of thinking makes clear the importance of more systemic perspective.

Beth:   I’m not sure what such a new picture of nature would look like.

CJ:       Understandably. We are only just beginning to recognize the question and find useful ways to think about it.  I’ve found help peronally in recognizing how my relationship with nature has felt decidedly different at different times in my life. If nothing else, nature’s new picture must somehow tolerate such multi-faceted validity.

When I was young, my relationship with nature might best be described as reverential. Nature was my cathedral, where I went when I needed to nourish myself and reconnect. Part of this was temperament, part my age, and part the Great Northwest where I grew up.

But that isn’t the only way I’ve experienced nature. I also grew up reading journals of my forebears coming over the Oregon Trail. While my ancestors certainly were respectful of nature, and very knowledgeable, they weren’t particularly delicate in how they related to her. Nature wasn’t an adversary, but the task was to tame her. I don’t criticize that. And I can feel some of it in how I relate to nature, in a toughness and respect that holds an important piece of truth. Certainly some of the decisions we will need to make in the future will require something akin to that toughness.

Nature’s role as resource has been no less significant in my life. The modern view that regards nature as something separate from us to utilize for human benefit is a dangerous dead end if we ignore limits. It blinds us to the intricate relationships through which nature works. But I drive a car that uses fossil fuel, live in a wooden house, and benefit from the economic prosperity harvesting of natural resources provides. Ignoring how nature physically serves us is a common causes of naive and counterproductive advocacy.

What then is nature—to me, and ultimately?  I can say comfortably that the new picture must somehow find a place for each of these very different relationships. It must also be able to articulate limits each of these views confront as final explanation. It must somehow reflect a more consciously all-the-crayons-in-the-box systemic picture.

Beth:   I think a more encompassing kind of picture will be important not just for making good choices in the future, but also for our sense of meaning and rightness—important for our souls. “Mother” nature is our biological home. Right relationship with her—I guess you would say “right and timely”—is critical to our emotional as well as physical safety and sustenance.

CJ:       I agree. We can also make a broader observation with regard to limits. Whatever the particular issue, addressing limits expands how we see the world in essential ways. In the end it does so not just for that particular issue. It point toward the more complex and complete kind of understanding on which future effectiveness and meaning depends more generally.