My job was simple: Write anessay reviewing four excitingbooks—two on the general

topic of health care justice, and two onhealth care policy. 1,103 pages of schol-arly discourse, and what did I find my-self thinking about? Swimming pools,of course.

I take care of patients within the Vet-erans’ Administration system. Most ofthem have limited financial means andsuffer from multiple chronic illnesses.Virtually all would be better off if theyexercised regularly. I urge many of mypatients to take walks, but a large num-ber of them cannot follow this advice.Some live in unsafe neighborhoods.Some have physical problems that limittheir ability to walk. Swimming poolsare one of their best exercise options.

But do you know how much it coststo use a swimming pool? In Ann Arbor,where I live, a single trip to a publicswimming pool costs four dollars. Visit-ing three times a week will set a patientback $624 per year. Many tell me thatsuch an expense is simply beyond theirmeans. We live in a country, it seems,where we are happy to pay for veterans’diabetes pills, hypertension medica-tions, and cholesterol pills, but not forthree visits a week to a pool where theymight begin to get in good enoughshape to get off some of their expensivemedicines.

Health problems like diabetes, hy-pertension, heart failure, and hyperlipi-demia (high cholesterol) are often theresult of complex social forces. That

means that the job of physicians like meis bigger than it used to be. It doesn’tend when we’ve checked a few bloodtests and prescribed the relevant pills.Many of our patients are sick becausethey eat too much or exercise too little.They suffer from stress due to badneighborhoods or financial problems,and the stress wreaks havoc on their car-diovascular and immune systems. Ablood pressure pill and a couple ofXanax simply won’t do the trick. If wewant to help our patients, we need toaddress the fundamental forces influ-encing their health—hence my obses-sion with things like affordable swim-ming pools. I am not naïve enough tothink that a swimming regimen willsolve my patients’ health problems, butI do believe that it would be a nice start:helping people burn calories and blowoff steam, encouraging positive socialinteractions, and maybe even buildingmuscle strength to protect their fragilejoints.

While I was reading these fourbooks, I was pleased to discover that Iwas not alone in my obsession. Whilemeeting with a physician who had justmoved to Ann Arbor from Philadelphia,where she had worked in a communityhealth center, I found that she, too, en-couraged her patients to swim and en-countered the same barriers I did. Beinga better person than I, though, she did-n’t give up, but instead took it upon her-self to compile a list of neighborhoodswimming pools, along with their pric-ing rate at various times of the week, to

distribute to her patients. Before she leftPhiladelphia, she had been planning tovisit these local pools to negotiate moreaffordable rates for her patients.

A physician who believes that her jobdescription includes negotiating swim-ming pool fees? Clearly, as more physi-cians recognize the broad societal forcesinfluencing people’s health, their view oftheir proper role will broaden. I expectthat many bioethicists—especially thosewho study issues of justice and resourceallocation—are also recognizing thattheir job description goes well beyondwhat it used to.

When I was first introduced to thefield of bioethics back in the early1980s, I took special joy from the sec-tion of the course dealing with healthcare justice. We wrestled with “lifeboatethics,” deciding (hypothetically) whoshould live and die if there were notenough dialysis machines or intensivecare unit beds to go around. Once we’dsolved these microallocation dilemmas,we moved on to the big picture stuff—the macroallocation issues such as, isthere a right to a decent minimum ofhealth care, and, if so, what does thatright entail?

H A S T I N G S C E N T E R R E P O R T 51July-August 2007

The Ethics ofSwimming Pools

by Peter A. Ubel

review

Social Justice: The Moral Foundationsof Public Health and Health Policy.By Madison Powers and Ruth Faden.Oxford University Press, 2006. 348 pages. Hardcover, $45.00.

Health and the Good Society: SettingHealthcare Ethics in Social Context.By Alan Cribb. Oxford UniversityPress, 2005. 250 pages. Hardcover,$85.00.

Medicine and the Market: Equity v.Choice. By Daniel Callahan and Angela A. Wasunna. Johns HopkinsUniversity Press, 2006. 334 pages.Hardcover, $35.00.

Poor People’s Medicine: Medicaid andAmerican Charity Care since 1965.By Jonathan Engel. Duke UniversityPress, 2006. 318 pages. Paperback,$22.95.

All these micro- and macroallocationissues remain relevant today. Althoughdialysis machines are now plentiful,transplantable livers and hearts arescarce, forcing administrators and clini-cians to make the same difficult deci-sions our class was making in the 1980s.And governments around the world stillstruggle to figure out which health careservices to guarantee to at least somesubset of their population.

But despite their continued rele-vance, these age-old allocation issuesseem so . . . so small now. In saying this,I am belittling my own profession andresearch career, which has focused inpart on these very same micro- andmacroallocation issues. Maybe I’m in amidlife crisis. But I have a hard timegetting excited about cadaveric livertransplantation any more.

The Job of Justice

The broadening of bioethics is ap-parent in each of these four books,

but perhaps nowhere more than in So-cial Justice: The Moral Foundations ofPublic Health and Health Policy. In thisexcellent book, Madison Powers andRuth Faden set out to define the essen-tial dimensions of well-being thatshould guide a theory of justice, andthen to show how such a theory can beapplied to important issues in publichealth and health policy.

That Powers and Faden emphasizewell-being rather than health is a hint ofhow broadly they define the goals ofjustice. The breadth of their theory iseven clearer when they lay out the sixdimensions of life critical to well-being.Not surprisingly, one of the dimensionsis self-determination, but this dimen-sion is the last one they describe. Al-though Powers and Faden do not ex-plicitly state that this position indicatesanything about the relative importanceof self-determination, I find it tellinggiven the importance that self-determi-nation has played in so many theories ofjustice (and bioethics). Self-determina-tion is central to both libertarian andnonlibertarian theories of justice. Yet, byplacing it last, Powers and Faden seem

to show that self-determination is nomore important than any of the otherdimensions.

Given this, we may reasonably askwhere they place income equality ontheir list. Issues of distributional wealthplay an important role in many theoriesof justice, from Marx’s “to each accord-ing to need” to John Rawls’s Maximinprinciple. But income distribution doesnot even make Powers and Faden’s list.Their list is based on determinants ofwell-being, and income distribution isonly a means to that end; whereas thesix dimensions that they write about arecentral components of well-being, im-portant as ends in themselves.

So what are the other five dimen-sions? One is health, which they definein ordinary-language terms: health iswhat people have when they are notsick. The absence of health occurs whenpeople lose biological functions, such asbowel function or sexual function, orwhen they experience pain. Their un-derstanding of the term health is pur-posefully narrower than the WorldHealth Organization’s definition ofhealth as a state of physical, mental, andsocial well-being. “The problem withthis noble aspiration,” Powers andFaden write, “is that it conflates virtual-ly all elements of human developmentunder a single rubric and thereby makesalmost any deficit of well-being into ahealth deficit” (p. 17). For Powers andFaden, health is an important compo-nent of well-being because it is a goodin its own right. But it is also desirableas a means to other aspects of well-being: people are more likely to flourishwhen they are in good health.

Well-being, by their account, alsodepends on four other factors: personalsecurity (freedom from unjustifiable co-ercion and violence, for example), rea-soning ability (people’s cognitive capaci-ties to make sense of and function with-in the world), attachment (the ability toform bonds of friendship and love), andrespect. “Respect and therefore well-being is set back whenever we are per-ceived as being of lesser value because ofmembership in a particular race, gender,economic class, or other group about

whom invidious judgments are made”(p. 23).

With these dimensions in mind,Powers and Faden set out to describethe job of justice:

Our list of essential dimensions ofwell-being is offered as an account ofthose things characteristically presentwithin a decent life, whatever a per-son’s particular life plans and person-al commitments. Moreover, each di-mension is important enough to bean independent concern of justice.The job of justice, positively stated, isthe task of securing a sufficient levelof each dimension for each individ-ual, in so far as possible. (p. 15)

A Broader Health CareEthics

It is hard not to think about thebreadth of health care ethics when

reading Powers and Faden’s book. Theo-ries of health care justice have typicallybeen put forth almost as subsets ofbroader theories of justice. A broad the-ory of justice attempts to figure outeverything about how to make a just so-ciety, but it may not deal with details inmuch depth. For example, Rawls’s influ-ential theory of justice barely refers tohealth or health care. By contrast, a the-ory of health care justice might try todetermine whether societies have anyspecial obligation to promote people’shealth or their access to health care.Norman Daniels, for example, famouslyrevisited Rawls’s theory of justice to seewhat it implied for debates about theright to health care.

Powers and Faden start off with avery broad set of dimensions to consid-er in doing the job of justice. Giventhese dimensions, their theory is, inmany respects, broader in its reach thanRawls’s theory. In what respect, then,does their theory act (to paraphrasetheir subtitle) as the moral foundationof public health and health policy? Itseems to go well beyond it. To success-fully balance their six dimensions ofwell-being, a society can’t just look at itshealth care system or its public health

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system, but must also look at its educa-tion system, its legal system, its taxationpolicy . . . the list goes on.

Powers and Faden are not alone inbroadening their scope beyond thearena of health care policy. In Healthand the Good Society, Alan Cribb setsout to look at health care ethics in a so-cial context. Like Powers and Faden, heis interested in how the health agendahas broadened over the years—from at-tacking diseases to promoting health,from caring for hospitalized patients tocaring for people in the community.And, like them, he explains why clinicalethics is becoming indistinguishable atits outer edges from public healthethics; and why public health ethics, atits outer edges, has become indistin-guishable from ethics more generally.Yet Cribb doesn’t set out to develop atheory of justice, and his book is a realslog at times. I’m not sure, for example,what audience he expected would easilydigest sentences like the following:“The crux of the sociological mind-setis the recognition that the actor and thesocial field interpenetrate one anotherand are mutually constitutive” (p. 9).When I read that sentence out loud tomy wife in bed one night to see if sheunderstood it, she rolled her eyes at meand said, “Not now, honey, I have aheadache.”

Health policy and health care are notexclusively about providing health—they necessarily have broader aims. Tomention just a few obvious examples,health policy clearly needs to take intoaccount things like patients’ wishes orpublic opinion, and arguably ends suchas equity or solidarity, which are all dif-ferent from health. In this broader con-text simple notions such as “efficiency”and “maximizing outcomes” automati-cally become problematic.

The Work of Bioethics

Where should a bioethicist begin toaddress issues of injustice? A col-

league of mine—another physician—hopes to work on bioethical issues with-in his clinical specialty of hepatology(the care of patients with liver disease).

In his practice, he encounters all kindsof ethical dilemmas: Is the current sys-tem of liver transplantation giving un-fair advantage to the sickest patients, re-gardless of their chance of benefitingfrom transplant? Are clinicians makingunjustifiable social judgments whenthey decide which patients to put onthe waiting list for a liver? What shouldhepatologists do to help involve patientsin their medical decisions? And so on.Each of these dilemmas is important,and many of them have life or deathconsequences. But are they importantenough—broad enough—to warranthis attention? Or should he focus onbigger issues—questions like: What arethe social determinants of alcoholicliver disease? And what are the healthconsequences when patients are unableto afford their hepatitis C medications?

As it turns out, the success of his re-search career is in large part determinedby powerful social forces. His world-fa-mous hepatology mentor encourageshim to narrow his interests—focus,focus!—so he can get his academic ca-reer on track. Recognizing these reali-ties, I also encourage him to focus,while at the same time helping himthrow in a few extra projects that hismentor need not be aware of. But evenso, I don’t push him to address the hugeissues affecting the health and, yes, thewell-being of his patients. Addressingthe issues of security, respect, reasoning,and the like prior to receiving tenurewould be career suicide for him.

What, then, should a posttenurebioethicist do? Clearly, she should pur-sue work she’s passionate about, andwork that will improve the world. Thiscould be small-scale work. Heck, mylife was improved the other day when,as I struggled to enter a building whilecarrying a heavy box, a stranger waskind enough to open the door for me.So I would never dismiss the value ofpursuing work that addresses relativelysmall issues or small numbers of people.Someone within bioethics, for example,needs to help transplant experts sort outthe ethical issues relevant to unrelatedliving organ donation; and someoneneeds to figure out what role, if any,health care providers should play in

making capital punishment more hu-mane (less inhumane?). But on thewhole, I believe that far more post-tenure bioethicists should be dealingwith the bigger issues.

Daniel Callahan has been addressingissues of broad importance for severaldecades now. His groundbreakingbooks on health care rationing havebeen written for academic and generalaudiences alike, with the goal of implor-ing the powers-that-be to rethink theinfinite demands inherent in the healthsystems of most industrialized coun-tries.

Callahan has teamed up with AngelaWasunna for a book called Medicineand the Market. Its goal is to assess thetradeoffs between equity and choice inhealth care delivery—something the au-thors accomplish by perusing dozens ofhealth care systems around the globe.Callahan and Wasunna point out that,despite tremendous variation in howdifferent countries have developed theirhealth care systems, almost every coun-try’s system is in need of a major over-haul. Inequities abound and costs soaralmost regardless of the system.

Many experts would have looked athealth care systems as necessarily mak-ing tradeoffs between equity and effi-ciency. But Callahan and Wasunna, inthe subtitle of their book, establish thatthe tradeoff is between equity andchoice. They convincingly show that, inhealth care, markets are famous formaximizing choice, not efficiency. In-deed, health care systems stand out fortheir inability to become more efficientas they become more market-oriented.

Callahan and Wasunna explore thegoals that countries juggle in decidingwhich parts of their health care systemto leave to market forces and which tohand over to government regulators, oreven government operators. They ask,“How far, and in what ways, can themarket go in that direction [maximiz-ing freedom] without doing harm tothe moral values of medicine, most no-tably the primacy of patient welfare andprofessional integrity?” (p. 36). Andthey answer, in line with many healtheconomists, that: “The balance to beachieved will and must reflect the cul-

H A S T I N G S C E N T E R R E P O R T 53July-August 2007

ture, politics, and history of differentcountries” (p. 41). Therefore, to under-stand the moral tradeoffs that anyhealth care system faces, we must un-derstand the cultural, political, and his-torical forces that have shaped thosehealth care systems.

In search of such understanding,Callahan and Wasunna set off on a nec-essarily abbreviated tour of the world. Athirty-five-page chapter outlines the his-tory of the Canadian and U.S. healthcare systems—a leisurely tour comparedto the two pages allotted to Western Eu-ropean countries like the United King-dom, Sweden, Switzerland, and Italy,and a glacial pace compared to the evenshorter descriptions of countries likeZimbabwe, India, and Vietnam. Hav-ing spent a month traveling in Vietnamin the 1990s, I felt I had a better under-standing of its health care system than Icould glean from this book. But Calla-han and Wasunna recognize their limits.Their descriptions of each country’shealth care system are intended only tohighlight the fascinating and varied mixof market and nonmarket forces thatcountries have tried.

Market and NonmarketMedicine

Nobel economist Kenneth Arrowpointed out in the early 1960s that

health care systems can never meet neo-classical conditions for a free market.And even if health care systems could beorganized completely around free mar-ket principles, few people argue that thiswould be desirable. Health is too im-portant to people’s well-being to leave itentirely to market forces.

Less often pointed out, however, isthat there is also no way to imagine acompletely nonmarket approach tohealth care. Imagine, for example, acountry that not only uses the govern-ment to fund health care delivery, butalso to provide it. In such a country,market forces will still determine whichpeople will become doctors and nursesand physical therapists (rather thanlawyers and accountants and construc-tion workers). People choose careers,

after all, in response to local marketforces. Even a nationalized health sys-tem has to deal with labor markets. Un-less the country dictates each person’sprofession, the health care professionswill need to compete for laborers withinbroader (that word again!) market-places.

Suppose the state controlled thechoice of occupations, though. Howwould hospitals in this country pay formedications? They would likely have tobuy medicines from international phar-maceutical companies, which operatewithin—you guessed it—the market-place. How much will this country’shospitals pay for MRI machines andCT scanners and x-ray equipment?Once again, the country is likely to de-pend on the international marketplace.Short of a dictatorial country surround-ed by an iron curtain wrapped within asteel wall embedded within a leadshield, all countries will have to dealwith market forces when cobbling to-gether their health care systems.

Consider the U.S. health care sys-tem, which has rightly been character-ized as one of the most market-orientedsystems in the developed world. In hisoutstanding book, Poor People’s Medi-cine, Jonathan Engel traces the historyof charity care in the United States sincethe establishment of Medicare andMedicaid in the mid-1960s. He de-scribes the myriad reforms that the U.S.government has pursued in an effort toimprove the health of the underprivi-leged. The U.S. system may be moremarket-oriented than most, but weshould remember that the governmenthas played a substantial role in healthcare in the United States for manydecades now. The percent of gross do-mestic product that the U.S. govern-ment spends on health care is currentlythe match of almost any other devel-oped country in the world. In the Unit-ed States, the government primarily hasacted as a third-party payer, taking taxmoney and turning it over to hospitalsand clinics, most of which are private.

But Engel reminds us that there wasa sizable government presence in healthcare delivery prior to Medicare andMedicaid. In 1950, public hospitals “ac-

counted for nearly a third of all hospitalbeds in the country.” And there was alsoa generous amount of pro bono care inthat decade, with most physicians andhospitals feeling duty-bound to providecare to people who could not pay for it.This pre-Medicare/Medicaid systemwas far from ideal. Many people—espe-cially elderly retirees—faced potentialbankruptcy if they became sick, and thehope that a public hospital or generousphysician would be willing to shrug offall their debt was not much consolationto them. Into this mess came Medicareand Medicaid, two programs that werepatched onto the existing system in anattempt to reduce the number of peopleunable to pay for their medical care,while at the same time avoiding mutinyfrom powerful hospital and physicianlobbies.

Medicare and Medicaid, of course,had far-reaching effects on the U.S.health care system. One particular effectis worth noting as an illustration of thecomplex interplay of market and non-market forces. Medicare and Medicaidseverely crippled the public hospital sys-tem and almost single-handedly (dou-ble-handedly?) reduced the private sys-tem’s willingness to offer charity care.

Public hospitals suffered becausetheir former clients now had a ticket toadmit themselves to the hospital of theirchoice. When the ticket was a Medicareplan, with its generous payments, itopened almost every hospital door.Medicaid recipients, by contrast, foundfewer doors opened to them, given thelower payments in most states. But still,most patients could choose from morehospitals than they could prior to Med-icaid. Consequently, by 1980, the frac-tion of public hospital beds in the coun-try had dropped from one-third to one-eighth.

Charity care plummeted, too. Priorto Medicare and Medicaid, cliniciansand hospitals usually took pity on pa-tients who were unable to pay for theirmedical care, perhaps reducing theirbills or looking the other way. But afterMedicare and Medicaid, doctors andhospitals looked to the government forpayment. And when the government re-fused to pay acceptable rates, they felt

54 H A S T I N G S C E N T E R R E P O R T July-August 2007

justified in turning patients away. Howelse would the government learn that itneeded to be more generous? Engel re-veals many fascinating twists and turnsas politicians (some noble, some igno-ble) tried to fix one problem only to cre-ate another and never figured out a wayto keep health care costs from skyrock-eting.

The Point of Debate

Of late, the popular media have fi-nally discovered the surprising effi-

ciency and quality of the place in whichI have been practicing medicine for thepast thirteen years: the VA system. Afterbeing overhauled by Ken Kizer in themid-1990s, the VA system has emergedas an American oddity—a health caresystem funded and operated by the gov-ernment that matches or exceeds theprivate system in almost every qualitymeasure assessed to date. And at a sig-nificantly lower cost!

The VA system is largely ignored byRepublicans in the United States today.It is a poor fit for their antigovernmentideology. But Republicans should notbe blamed too heavily for this oversight.The VA system was largely ignored bythe authors of these four books, too.

Why aren’t more people talkingabout the VA system? I suspect that it issimply too much of an anomaly for any-one to make much use of it in dis-cussing how to reform the U.S. healthcare system. The VA cares for a group ofpatients who either have recourse toother systems—patients with no insur-ance who go to, say, a VA cardiologistand then to a private orthopedist—orwho have no other alternative andtherefore are largely grateful for whatev-er care they can get. For the most part,these patients receive fine care, withmore appropriate management of theirdiabetes and congestive heart failure andemphysema than they are likely to re-ceive outside the VA system. The VAelectronic medical record is a marvel,enabling clinicians to coordinate patientcare, minimize prescription errors, andremember when to screen their patientsfor colon cancer.

But the VA system has serious flaws,too, which are often overlooked in therecent media glow. To control costs, theVA limits the services available to pa-tients. I saw a patient last year who hada visibly swollen jaw due to a tooth ab-scess, and all I could do for him wasprescribe an antibiotic and give him alist of local dentists’ phone numbers.The VA refused to cover any of his den-tal problems. The VA also controls costsby limiting the number of specialistsavailable to its patients. Most patientsoutside the VA system would probablynot tolerate a six-month wait for an or-thopedic appointment.

The VA system may fail to work as amodel for the U.S. system for anotherreason—one brought out in all four ofthese books. The VA system is simplynot in tune with U.S. culture. No onethat I know seriously believes that theU.S. will ever move to a nationalizedhealth care system, with the governmentboth funding and providing health careas it currently does within the VA sys-tem.

Which brings me to another ques-tion: Should we debate whether there isa right to a decent minimum of healthcare? As I mentioned earlier, I was excit-ed in college when I came across debatesabout whether there is a right to healthcare, and what such a right would en-tail. But now, I have to ask whethersuch debates deserve a prominent placein bioethics. These debates are of limit-ed use, in part, because they seem to fallso out of line with mainstream thinkingin U.S. culture. The brilliant essays Iread during college were mostly writtenprior to Ronald Reagan’s presidency.The culturally acceptable role of govern-ment in people’s lives has come undersuch constant attack since then that itseems more useful to argue about Wal-Mart’s role in health care than the gov-ernment’s.

Such debates also appear to be oflimited use because they fail to get at theroot of the problem. As horrendous as itis to have a country where more thanforty million people lack health insur-ance, this inequity is merely a symptomof a much broader ailment. The UnitedStates is rapidly developing disparities of

wealth that rival those seen in develop-ing nations. Social epidemiologistsmake the case that such disparities havefar more damaging effects on people’shealth than do health care disparities.Whatever you think of the U.S. healthcare system, it does a pretty amazing jobof caring for people when they are inthe middle of heart attacks. But unfor-tunately, the cultural and political mi-lieu in the United States also perpetu-ates disparities that lead to dispropor-tionate numbers of heart attacks amongthe most vulnerable members of society.

What is the point of debating a rightto health care? Maybe we should, a laPowers and Faden, be debating the rightto a decent minimum of well-being. Irecognize that debates about topics likethe right to health care are one way ofchanging our culture. Societies evolve,after all, and academic discourse—aswell as op-ed pieces, books for generalaudiences, and television debates—allserve to influence people’s thinking. Tostop debating these issues is to give upon improving our society. On the otherhand, I wonder whether the job ofbioethics needs to grow. Rather thansimply try to change society throughlogic and argument, maybe bioethicistsshould play a larger role in helping de-vise health policies and health-relatedpolicies. And in doing so, maybebioethicists should consider wanderingover to new areas. Given the importantrole that education and income dispari-ties play in people’s health and well-being, maybe bioethicists should be de-bating education and taxation policies.

Maybe it’s even time for them to getpassionate about swimming pools!

H A S T I N G S C E N T E R R E P O R T 55July-August 2007