Correspondence

Metaphors and Health Care Reform

N Engl J Med 1995; 333:259-260July 27, 1995

Article

To the Editor:

Annas (March 16 issue)1 discusses the importance of metaphors in the debate on health care reform and argues for a new metaphoric framework based on ecology. Although it may be stretching the point, I propose that the entitlement metaphor is a key determinant of the approach to health care.

The third-party–payer system turned medical care into an entitlement for most people in the United States (although now for a decreasing number). The influence of the entitlement metaphor is pervasive. It affects the way everyone looks at medical issues — not just patients but physicians, legislators, and policy planners alike. The metaphor allows us to sidestep the question of cost, as well as the distinction between convenience and necessity in many cases. People often tell me, “Oh, don't worry about that; I have good insurance,” or “I've already met my deductible, so I don't really care what it costs,” or (my favorite) “You don't have to give me the generic brand of the drug. I've got a prescription card.” Yet most people are very conscious of cost when shopping for groceries, cars, or furnaces. The big difference, of course, is whether we, or a third party, must pay for the products or services. When we perceive that someone else is paying the bill, we release ourselves from responsibility or accountability. Physicians are often loath to bring up the subject with patients or family members who are concerned only with the results of medical care and wish to “do everything.”

J.D. Wright, M.D.
300 N. Madison St., Joliet, IL 60435

1 References

1. 1

   Annas GJ. Reframing the debate on health care reform by replacing our metaphors. N Engl J Med 1995;332:744-747
   Full Text | Web of Science | Medline

To the Editor:

Annas's proposed ecologic metaphor for health care reminds us of limited resources, integrity, diversity, and responsibility to the “system.” But the metaphor obscures the central role of the physician–patient relationship in the delivery of health care.1 Ecologic language may also distort the intimate relationships within families and between family members and their physicians.

Metaphors remain in vogue for only a limited time. It is questionable whether the ecologic metaphor will be any more efficient in leading us to a consideration of what Gaylin calls the “deeper issues of health care — our attitudes toward life and death, the goals of medicine, the meaning of health, suffering versus survival, who shall live and who shall die (and who shall decide).”2

It is time to abandon our dependence on metaphors and use the language of human rights. A human-rights approach requires that a discussion of health care reform go beyond the simple matter of cost containment. Health care is a social good, not a commodity, and principles of justice, equity, and social obligation need to be at the foundation of health care reform. The recognition of a right to health care creates correlative obligations or duties to act in a responsible manner so as to develop integrity, create community, value quality (of life), and conserve limited resources for future generations. The debate can be invigorated if physicians join with patients in recognizing this right. As long as access to health care is based on sex, race, economic status, social position, or any other nonmoral criterion, I fear we will never have the wide-open, far-ranging public debate about the deeper issues of health care that Annas believes is necessary for true reform.

Theodore D. Masek, M.D.
110 Velwood St., Redlands, CA 92374

2 References

1. 1

   Wolf SM. Health care reform and the future of physician ethics. Hastings Cent Rep 1994;24:28-41
   Web of Science | Medline

2. 2

   Gaylin W. Faulty diagnosis: why Clinton's health-care plan won't cure what ails us. Harper's. October 1993:57-62.
   

To the Editor:

Recently, I was notified by Blue Cross–Blue Shield that, as part of their recredentialing process, they needed to verify my internship and residency training. I telephoned the company to suggest that it might be easier if they contacted the credentialing office at Boston University Medical Center, where I have been a member of the faculty for the past 20 years. I was taken aback by the response: “We are required to check the quality of our line of products.” This wording brought to mind the market metaphor, as discussed by Annas. Am I the product being sold to the company's customers? This depersonalizing attitude on the part of health care organizations may itself be diminishing the quality of their products.

Irene Gavras, M.D.
Boston University School of Medicine, Boston, MA 02118-2394

Author/Editor Response

Professor Annas replies:

To the Editor: Gavras correctly notes that depersonalizing market metaphors are proliferating in medicine. Such metaphors affect how physicians and the public think about themselves and health care. My favorite new market metaphor, which refers to the amount of money a health maintenance organization (HMO) actually spends on the delivery of health care to its members, is the “medical loss ratio,” or simply, the “loss ratio.”1 Not only are physicians seen as products, but the medical services they deliver are viewed as losses. This metaphor makes it appear that the ideal physician is one who is listed on an HMO's roster but is never actually seen by any members.

Both Wright and Masek point to legal metaphors — Wright as a source of our problems, and Masek as a solution to them. There is little question that our view of entitlements affects our view of what is reasonable to expect from medicine. The real question is how to change the sense of entitlement. The ecologic metaphor, with its inherent recognition of limits, seems the right approach to the problem. Likewise, although I agree with Masek that a human-rights approach to health care is important,2 the question is how to reach this goal. Military and market metaphors both ignore human rights; the ecologic metaphor can accommodate them. Metaphors, of course, obscure reality as well as emphasize selected aspects of it. To the extent that we can focus on the real health care needs of real people, we will be most likely at least to try to develop a health care system that is responsive to those needs.3

George J. Annas, J.D., M.P.H.
Boston University Schools of Medicine and Public Health, Boston, MA 02118

3 References

1. 1

   Freudenheim M. A bitter pill for the H.M.O.s. New York Times. April 28, 1995:D1.
   

2. 2

   Annas GJ. The rights of patients: the basic ACLU guide to patient rights. 2nd ed. Carbondale: Southern Illinois University Press, 1989.
   

3. 3

   Pellegrino ED. Words can hurt you: some reflections on the metaphors of managed care. J Am Board Fam Pract 1994;7:505-510
   Medline