"When a community loses its memory, its members no longer know one another. How can they know one another if they have forgotten or have never learned one another’s stories? If they do not know one another’s stories, how can they know whether or not to trust one another? People who do not trust one another do not help one another, and moreover they fear one another, and this is our predicament now. Because of a general distrust and suspicion, we not only lose one another’s help and companionship, but we are all now living in jeopardy of being sued.
"We don’t trust our “public servants” because we know that they don’t’ respect us. They don’t respect us, as we understand, because they don’t know us; they don’t know our stories. They expect us to sue them if they make mistakes, and so they must insure themselves, at great expense to them and to us. Doctors who are in a country community must send their patients to specialists in the city, not necessarily because they believe that they are wrong in their diagnoses, but because they know that they are not infallible and they must protect themselves against lawsuits, at great expense to us. . . .
"Several decent family livelihoods are annually paid out of the county to insurance companies for a service that is only negative and provisional. All this money is lost to us by the failure of community. A good community, as we know, insures itself by trust, by good faith and good will, by mutual help. A good community, in other words, is a good local economy. It depends on itself for many of its essential needs and is thus shaped, so to speak, from the inside-unlike most modern populations that depend on distant purchases for almost everything and are thus shaped from the outside by the purposes and the influences of salesmen." (157-158)
"The loss of local culture is, in part, a practical loss and an economic one. For one thing, such a culture contains, and conveys to succeeding generations, the history of the use of the place and the knowledge of how the place may be lived in and used. For another, the pattern of reminding implies affection for the place and respect for it, and so, finally the local culture will carry the knowledge of how the place may be well and loving used, and also the implicit command to use it only well and lovingly."(166)
(From the 1990 collection What Are People For?)
Berry argues that local culture is dependent upon relationships of face-to-face trust and mutual life and involvement in the day-to-day business of work and worship and play. Without that trust, we have a culture of personal protectionism and tort that renders our healthcare fraught with impersonality and consumerism. While Berry does not suggest this directly, I think his chief insight is that healthcare should not be commodified to begin with. Medicine does involve money, but when we make medicine and health a matter of market relations we have already started down the road to a broken system, one lacking personhood and genuine compassion; that is, one that is is neither healthy nor caring.
Of course, I am not denying that doctors should have a reasonable livelihood, as should medical researchers and educators. (Though, pharmaceutical reps are another matter entirely. . . ). Nonetheless, we currently have a system where much of our health and sickness is turned over to people we do not know and that we must trust despite our lack of any true knowledge of who they are or what their characters are like. And because we have commodified medicine and medical care, the natural and unnatural inequities in wealth have given rise to a state where strangers decide whether our sickness is worth giving much or any attention to, and where expensive procedures may easily devastate poor and working families in short order. We decontextualize health by making it a matter of management and numbers, rather than persons, their stories, and our relations with them in our communities.
A national system, which hopes to fix these problems, may or may not help curb the current excesses, but I doubt whether it can finally heal them. It participates in the anonymity and dangerous policy-decisions of technocrats who believe they know best what others need, though in all honesty, these are just numbers on a ledger to be balanced. Any system that robs us of our personhood and reduces us to an aggregate of material individuals is already shoddy in its workmanship from the get go.
If you demand of me money for numbers on a ledger to serve those I do not know, then understandably, it might feel like robbery, but if you speak to me of helping Toby and his premature twin daughters or David's cherished aging father or my own brother with mental retardation, then health and care become meaningful again, matters involving people whom we love.
Several notes.
ReplyDeleteFirst - I agree with you and WB that torts are a problem. If you are arguing that torts should be capped, then I am right there with you. However, the torts and 'commodifying' of medicine are not closely related, if at all, even though he in his writing and you in your comments use these terms almost as one rising out of the other.
Second - its a huge leap to say that since medicine is market-based, or involves money, then it is a broken system. This statement surely needs more justification. Why exactly is it inhumane to base a system on allowing valuable services to be bid upon? Why is it lacking genuine compassion? Could I not argue that it is the ultimate compassion when a stranger spends his youth, while I play, studying hard and long, so that when I need him for a surgery, I can dial a number and he is there for me? In some ways, this is about as close that we can get to Christ's words, "greater love has no one than this, that one lay down his life for his friends". Let us not rush in to accuse doctors of being greedy cold hearted ones (or the pharmaceutical companies) when they, without being prodded, work many sleepless nights to make it possible for us to live!!!
And - remember, friend, that it is not the 'expensive procedures' that devastate the poor family; it is the sickness that does it. Hehehe, the point is so simple that it is humorous. The procedures make them better, or else they would not turn every rock to find a penny to pay for them!
Finally - it is understandable that we might yearn for simpler time when we knew others' names. But I can tell you, that when my son said his stomach hurts, and he cried, and my heart ached for him, I can tell you honestly that I did not care one iota about the name of the stranger who saw him in the middle of the night, took an analysis, or the people in the company that made the antibiotic that healed his infection. I did not need to trust these people because I knew their stories. In fact - I had the freedom to go to people whose stories I knew, but I knew that these people could not be nearly as good as the people at Cook Children's hospital in Fort Worth, in whom I trusted because of the diplomas on their walls, not because of their stories or some common past. I did not resent them. I did not call them robbers. In fact, I literally thanked God that day, that I did not live in some yester-year where wonderful communities lived in villages, and children whithered away and died from urinary tract infections, because of a lack of highly trained impersonal medical specialists.
Another point just for fun; how far would WB take this need to base our transactions on knowing each other. If modern city is not good, since we don't know strangers there, and village is better, then is a neighborhood better than a village? Surely we can trust a neighbor more than we can trust a doctor clear across a village, right? We know the neighbors' stories better than we do villagers'. And - if a neighborhood is better than a village, then is a family better than a neighborhood? Again - we know the family-members stories even better! Let us seek medical care from those we really trust - our family members. Of course this would be absurd, but ask why? Because family members are not specialists, are they? So it almost seems that the doctor's expertise is more important than his 'story', after all.
Much of what you've pointed out here are my dissatisfactions with the post as I mentioned to you in passing yesterday. I agree that a return to the local community that Berry loving recalls is mostly impossible, though I think keeping the ideal in mind can shape our choices about where we live, shop, eat, and in general how we treat people. In the real world of current healthcare, I think anything that can be done to make things more stable, face-to-face, and local is good.
ReplyDeleteAlso, I am not convinced that there is any direct relation between current impersonal health care and modern technologies, so the village without sanitary conditions seems like a misnomer. Once you introduce current medical doctors and techniques into a village, does it cease to be a village? (Maybe I'm wrong here, any thoughts? Does the technology itself force a change?)
You are also right to point out that expertise in modern medicine trumps local relations when we have an illness, but I don't see why that undercuts Berry's main point. Let's say, God forbid, that the antibiotic goes bad or didn't work with your son and he is harmed or even dies, would you less likely to sue if you knew the doctors involved? Likewise, would tort be less of an issue if we knew more of the people involved at every stage of the way?
Doesn't it change things that I know the Benkes (Ear-Nose-Throat), the Glovers (Dentist) in my town quite well, as well as have good relations with Daleys (my primary care) who've with met at school events, charity functions, and so on? They each have an expertise, as well as a story that binds me to them in a way that I am not bound to those I do not know, and yes, I trust them more as a result.
As to the expense issue, I'm somewhat ignorant, but I'm not convinced that the cost of the procedure must be what it often is. Of course, the sickness is what starts the problem, but what if that procedure were offered free or at low cost?
Let me stress that I am not against markets or money per se. The inhumane factor has the potential of entering healthcare when the market value of something trumps other more human concerns. To cite Ted Benke as an example. I know for a fact he has donated services and procedures on several occasions when families we know have been unable to afford them. Is this as likely to happen when medical cost is driven by what people are willing (or forced often) to pay? (I use the word "forced" here because a choice between bankruptcy and death or even near poverty and grave debilitation is hardly a choice.)
Is a service plan provider (which is my real problem here) who makes choices constantly on the basis of monetary deals with drug companies and the general cost of procedures going to do so with compassion as a driving value?
Ok, I'll stop here. I really am open to your views on this, by the way.
Oh, one more thought: I'm for tort caps, too, but I wonder if Berry would see them as the wrong end of the problem. Would he say that we're just trying to artificially limit the effects of mistrust rather than deal with the root problem?
ReplyDeleteBy the way, what I'm most interested in hearing Jekabs' critique on is this: Why can't certain health devices and procedures of either a) high volume need and/or b)rare and expensive cost simply be removed from a market system? Why can't we just offer them freely and let the work of the doctors, the cost of producing the materials, and the cost of any electricity involved be recouped in other ways? Sort of a pro bono of health care?
ReplyDelete