Quality, Mercy, and the Moral Determinants of HealthDonald M. Berwick, MD. MPPPresident Emeritus and Senior FellowInstitute for Healthcare Improvement

National Academy of Social InsuranceHealthcare Coverage and Costs:

Assessing Medicare-Based Approaches

Washington, DCMarch 5, 2020

Portia in The Mechant of Venice

The quality of mercy is not strained.It droppeth as the gentle rain from heavenUpon the place beneath. It is twice blest:It blesseth him that gives and him that takes.'Tis mightiest in the mightiest; it becomesThe thronèd monarch better than his crown.

— Portia, in William Shakespeare, The Merchant of Venice, Act 4, Scene 1.

Evan Berwick

Seven Grandchildren – Thanksgiving, 2019

June

Caleb

Sylvie

Evan

NaomiZoe

Nathaniel

Mercy… Evan Style

“It’s my magic wand… I’m trying to make Donald Trump happy.”

Allée des Justes

Allée des Justes

Le Mur des Justes

“…overcame the indifference that seemed to hold sway in our land... They felt a sense of commitment and responsibility toward their fellow human beings.”

Avedis Donabedian

“(U)ltimately, the secret ofquality is love. You have tolove your patient; you haveto love your profession; youhave to love your God.”

W. Edwards Deming

“All anyone asks for is a chance to work with pride.”

A Definition of “Quality”

“Quality” is the degree to which the results of the work you do match the needs you

intend to meet.

The quality of mercy.

The quality of mercy.The mercy of quality.

École des Garçons

“More than 11,000 children….”

“Arrested by the police of the Vichy Government, complicit with the Nazi occupation, more than 11,000 children were deported from France from 1942-1944 and murdered at Auschwitz because they were born jewish. More than 500 of those children were living in the 4th Arrondissment, among them the students at this school. We will never forget them.”

Jill Lepore: These Truths: A History of the United States

Thurgood Marshall

Homeless Children in New York City

The New York Times, October 15, 2018

Woolf and Schoomaker, JAMA, November 26, 2019

“Between 1959 and 2016, life expectancy increased by almost 10 years , from 69.9 years in 1959 to 78.9 years in 2016…

US life expectancy peaked in 2014 and subsequently decreased significantly for 3 consecutive years.”

Copyright 2019 American Medical Association. All Rights Reserved.

From: Life Expectancy and Mortality Rates in the United States, 1959-2017

JAMA. 2019;322(20):1996-2016. doi:10.1001/jama.2019.16932

Age-Specific, All-Cause Mortality Rates Among US Youth, Aged 1-24 Years, 1999-2017Source: CDC WONDER.

Figure Legend:

Copyright 2019 American Medical Association. All Rights Reserved.

From: Life Expectancy and Mortality Rates in the United States, 1959-2017

JAMA. 2019;322(20):1996-2016. doi:10.1001/jama.2019.16932

Age-Adjusted, All-Cause Mortality Rates, US Adults Aged 25-64 Years, 25-44 Years, and 45-64 Years, 1999-2017Source: CDC WONDER.aThe lowest mortality rates per 100 000 (and the years they were achieved) are listed first in parentheses; mortality rates for 2017 listed second.

Increase in Midlife Mortality:• New Hampshire: +23.3%• Ohio: +21.6%• Indiana: +14.8%• Kentucky: +14.7%

Angus Deaton and Anne Case – Princeton University

Date of download: 11/30/2019 Copyright 2019 American Medical Association. All Rights Reserved.

From: Life Expectancy and Mortality Rates in the United States, 1959-2017

JAMA. 2019;322(20):1996-2016. doi:10.1001/jama.2019.16932

Increased Death Rates from:• Drug Overdoses: +386%• Alcoholic Liver: +41%• Suicide: +38%• Hypertension: +79%• Obesity: +114%

Simon G. Talbot, MDWendy Dean, MD

A Manifesto on Quality and Mercy

• Intentional harm cannot be ignored.• There is no quality without compassion.• There is no quality without justice.• There is no quality without inclusion.• We have a duty to protect the commons.• It is not enough to bear witness – we must act.

Martha C. Nussbaum – Political Emotions: Why Love Matters for Justice (The Belknap Press, 2013)

“(A)ll of the core emotions that sustain a decent society have their roots in, or are forms of, love… (G)ood laws rarely come into being or remain stable over time without emotional support.”

The 100,000 Lives Campaign Bus Tour

1200 Seats in Camp Randall Stadium

Shylock’s Defense

“Hath not a Jew eyes? Hath not a Jew hands, organs, dimensions, senses, affections, passions; fed with the same food, hurt with the same weapons, subject to the same diseases, healed by the same means, warmed and cooled by the same winter and summer as a Christian is? If you prick us, do we not bleed?”

“IMAGINE THAT YOU SEE THEWRETCHED STRANGERS…..”

Grant them removed, and grant that this your noiseHath chid down all the majesty of England;Imagine that you see the wretched strangers,Their babies at their backs and their poor luggage,Plodding to the ports and coasts for transportation,And that you sit as kings in your desires,Authority quite silent by your brawl,And you in ruff of your opinions clothed;What had you got? I’ll tell you: you had taughtHow insolence and strong hand should prevail,How order should be quelled; and by this patternNot one of you should live an aged man,For other ruffians, as their fancies wrought,With self same hand, self reasons, and self right,Would shark on you, and men like ravenous fishesWould feed on one another.

- The Booke of Sir Thomas More: Act 2, Scene 4A Plea on Behalf of Immigrants

“For other ruffians… would shark on you.”

Imagine that you see the wretched strangers,Their babies at their backs and their poor luggage,Plodding to the ports and coasts for transportation,And that you sit as kings in your desires,Authority quite silent by your brawl,And you in ruff of your opinions clothed;What had you got? I’ll tell you: you had taughtHow insolence and strong hand should prevail,How order should be quelled; and by this patternNot one of you should live an aged man,For other ruffians, as their fancies wrought,With self same hand, self reasons, and self right,Would shark on you, and men like ravenous fishesWould feed on one another

New Quality Campaign:A campaign for the moral determinants of health.

A Campaign for Morality:

1. Achieve US ratification of major human rights treaties.

A Campaign for Morality:

1. Achieve US ratification of major human rights treaties.• International Covenant on Economic, Social, and Cultural Rights.

A Campaign for Morality:

1. Achieve US ratification of major human rights treaties.• International Covenant on Economic, Social, and Cultural Rights.• The Convention on the Elimination of All Forms of Discrimination

Against Women.• The Convention on Rights of the Child.• The International Convention on the Protection of the Rights of All

Migrant Workers and Members of Their Families.• The Convention on the Rights of Persons with Disabilities.

A Campaign for Morality:

2. Make health care unequivocally a human right in our nation.

A Campaign for Morality:

3. Restore American leadership to reverse climate change.

A Campaign for Morality:

4. Achieve radical reform of our nation’s criminal justice system.

A Campaign for Morality:

5. End policies of exclusion and achieve compassionate immigration reform.

A Campaign for Morality:

6. End hunger and homelessness in our nation.

Father Greg Boyle

“Here is what we seek: A compassion that can stand in awe at what the poor have to carry, rather than stand in judgment at how they carry it.”

John Rawls

“…in a well-ordered society, inequalities of wealth and income will be permitted only when they improve the situation of the worst-off.”

A Campaign for Morality:

7. Restore order, dignity, and equity to our democratic institutions, and assure the right of every single person’s vote to count equally.

A Campaign for Moral Determinants of Health

1. Achieve US ratification of major human rights treaties.2. Make health care unequivocally a human right in our nation.3. Restore American leadership to reverse climate change.4. Achieve radical reform of our nation’s criminal justice system.5. End policies of exclusion and achieve compassionate immigration

reform.6. End hunger and homelessness in our nation.7. Restore order, dignity, and equity to our democratic institutions,

and assure the right of every single person’s vote to count equally.

What To Do? – Individuals

• Speak• Write• Work• Vote

What To Do? – Organizations

• Guarantee to your workforce a local living wage.• Identify and end structural racism and discrimination

within your walls.• Commit to carbon neutrality by 2040.• Reach into the criminal justice system.• Lead and help in community-wide elimination of food

insecurity, homelessness, and educational failure.• Work for full voter participation in elections.

A Campaign for Moral Determinants of Health

1. Achieve US ratification of major human rights treaties.2. Make health care unequivocally a human right in our nation.3. Restore American leadership to reverse climate change.4. Achieve radical reform of our nation’s criminal justice system.5. End policies of exclusion and achieve compassionate immigration

reform.6. End hunger and homelessness in our nation.7. Restore order, dignity, and equity to our democratic institutions,

and assure the right of every single person’s vote to count equally.