'Public' Health vs. 'Private' Health

January 23, 1991|By RONALD DWORKIN

Public policy views the health-care crisis as basically acute and transitory. Like other contemporary problems, such as pollution and global warming, the crisis in health care is believed to be a technical problem confined to the last decades of the 20th century. For this reason, the health-care debate is rarely intellectualized. Economics, not philosophy, is expected to provide the relevant and practical solutions.

I believe, however, that the crisis in health care is in part a product of longstanding intellectual assumptions about health care. One example is the division between prevention and cure.

Medical science logically separate prevention and cure. Preventive medicine is directed toward the healthy individual to prevent the onset of disease. Curative medicine helps individuals after the onset of disease.

This division is scientifically meaningful, but only in the U.S. is the division organizationally significant. Only the U.S. has attempted to relegate preventive medicine to ''public'' institutions and curative medicine to ''private'' institutions (such as private insurance carriers or HMOs).

There is a robust philosophical position underlying this division of duties.

Preventive medicine is blameless medicine. It deals with illnesses that afflict individuals, but it does not fix blame on those who are stricken. It is believed to deal with problems that affect the community as a whole, such as infections spreading from contaminated food or unregulated sewage. Sickness, in these cases, is not considered to be the patient's fault. Hence it becomes a legitimate sphere of government activity in the form of ''public'' health.

Curative medicine is the teatment of the blamed. Public health laws rim an arena of disease that is believed to retain an element of individual choice. With churchy condescension, illnesses such as cancer and congenital defects are lumped together with alcoholism and obesity in a department of vice. Aid can no longer to be expected to come from government, since it would mean using public funds to correct problems that arose only because individuals had defective characters. Curative medicine remains in the ''private'' sector.

But disease is often not a product of individual miscalculation. The issue of personal choice as a causal factor in disease is rare. Therefore, it is absurd to block aid to patients out of a fear that it would reward personal vice and constitute an incitement to welfarism.

The rigid division between the duties of public health and private health is largely historical. It is no longer adhered to in strict fashion. Government, for example, now funds curative medical care for the aged in the form of Medicare. But the mentality persists.

It prevents government from comfortably supporting prenatal care or early treatment programs for hypertension because those are considered to be curative services. Those programs are firmly situated in the realm of private health and individual responsibility. It deters some private insurance organizations from comfortably supporting cancer-detection programs, preventive dental care and preventive medical programs that would reduce infant mortality. Those services are preventive in nature and, therefore, firmly anchored in government activity.

In each case, disease is allowed to progress because philosophy has arrested the impulse to treat. There is still a reluctance by each party to cross a line that does not belong.

This article is not written in support of either more government intervention in the health-care system or a greater role for private medicine in health care. It is written to encourage the abandonment of a social philosophy that continues to shape and direct two branches of medical science. It is written to encourage both public and private institutions to coordinate their JTC

preventive and curative activities so that the natural process of disease can be arrested at the earliest moment, in accordance with the purpose of medical science. It signifies an attempt to reduce the pain and financial expense of medical morbidity that arises unnecessarily in the gulf dividing ''public'' health and ''private'' health.

Dr. Dworkin is a physician who is also doing graduate work in government at the Johns Hopkins University.

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