Costs of Political Intermediation and Sustainability of the European Social Model in Health Care: the Dutch Example

5. Freedom of Choice in Health Care: Significance and Implications

As already mentioned, in the Dutch model companies can compete to gain market share also by offering supplementary insurance and that can also include non-essential treatments or treatments that are the subject of recurrent philosophical or moral controversies, such as cosmetic surgery and alternative medicine. The point is interesting as it stimulates a discussion on the scope that should be recognised to individual “freedom of choice” in health care in a free and pluralistic society: the formula is usually merely related to the choice of service providers.
Defining what is a medical treatment that is socially necessary to guarantee to every individual, and distinguishing it from what is not, entails a discussion in which effectiveness of treatment, equity and social solidarity issues are overlapped by others. These concern different personal views of the world and different lifestyles. In open and increasingly plural societies, even medical treatments can be, and as a rule increasingly are and will be, the subject of very different evaluations.
First, what is to be considered essential to guarantee everyone a decent life can no longer be taken for granted or merely determinable on the basis of technical and “objective” criteria. This is a good reason for limiting treatments guaranteed on solidarity bases solely to those proved necessary and effective according to the evaluation of the international scientific community and the need for which is almost unanimously shared by society. This limitation not only enables us to concentrate all the available funds raised through taxes (or through the contribution required of all the insured in the Dutch and Swiss systems), that are by definition scarce, on the full satisfaction of those needs, thus ensuring their sustainability over time. It also allows the leaving out of compulsory contribution those charges that a more or less sizeable part of society may regard as non-essential, at least if compared to others, or even inappropriate, but that can equally be considered by others as absolutely essential for an acceptable quality of life. On the other hand, in a strictly regulated insurance market such as that implemented with the Dutch reform, even non-essential treatments that would otherwise be out of reach for many could become relatively affordable. It is in fact also through the offer of supplementary insurance that companies can compete for market share and thus entice customers into buying their basic package.
Enforcing a strict distinction between essential and non-essential care also means preserving the health care funds forcibly taken from all beneficiaries from the abuse that the widespread rise of political populism and anti-scientific irrationalism will otherwise make “democratically” inevitable. Just consider for example the field of “alternative” medicine, the trust placed in this by both Western Third-Worldists distrustful of technological medicine, and by many immigrants (such as many Chinese), now a consolidated and stable part of the European population, increasingly European citizens themselves. Or think of treatments deemed ineffective by the scientific community, but the subject of extraordinary investment of trust by very large sectors of public opinion, who place in them quasi-religious hopes.
Years ago in Italy an unprecedented squandering of public health care resources took place, in order to finance a large-scale clinical trial of a treatment, the “Di Bella treatment”, considered ineffective by the scientific community and therefore completely useless and reckless. The mass clinical trial was imposed on the government by massive public demonstrations, supported and instigated by irresponsible political and media charlatans. Their pressure was impossible to resist by those in charge of the public health care system, as the instigators cynically played on the desperation of patients suffering deadly disease, and their relatives. The funds necessary for that useless trial were obviously taken away from treatments of proven effectiveness in the same field, that of cancer care, or in other branches of medicine. Despite the damage caused to public finance and to taxpayers by this irresponsible initiative, the instigating politicians who had organised that campaign not only were never held accountable in any way, not even politically. Instead they were allowed to gain profit in terms of visibility, popularity, electoral approval and political power, in that particular case, managing to win the regional government of Lazio and its health care machine, causing, not surprisingly, its complete financial breakdown.
In a free society, citizens have a right to be superstitious, as there is no objective criterion, that is not arbitrarily discriminatory, to distinguish superstition from the increasingly diversified beliefs definable as religious. Nor are there possible objective dividing lines between what is and what is not “religious”. The job of public authorities, in a free society, does not include defending from themselves adult and sane citizens who want to harm themselves — or do what Western-minded people like this author, the better informed, the majority (perhaps, and for the time being) of public opinion, the scientific community or the still reasoning sectors of the political establishment consider to be self-injury. But, increasingly, maintaining the political monopoly over the management and direction of health care will inevitably make it compulsory to “democratically” take into account a variety of insights on the world that now irreversibly include those scornful of “scientism” and who equate scientific knowledge and superstition, technological medicine and “traditional” medicine. New “Di Bella cases” will certainly arise in the future and, again, even the most upright politicians will be forced to bow, if they want to survive politically, to the uncontainable pressure of political and media charlatanry. Separating the fields also permits the limiting of claims for solidarity contribution to health care funding to those necessary for the provision of really essential treatments, of proven effectiveness and on which there is general consensus in the scientific community, without causing resentment or otherwise unavoidable collective psychosis, and without discriminating against the hopes, beliefs, religions and superstitions of the supporters of the new rising primitivism and irrationalism.
Nothing should prevent those so wishing from purchasing on the market and at their own expense all the other “alternative” treatments they think they cannot do without. They should be able to do so, if they wish, by entering into private contracts supplementary to the mandatory health care insurance, perhaps provided that the concerned treatments though maybe utterly useless, are not proven harmful, and provided they are not fraudulently advertised as having proven therapeutic effectiveness and risks are not hidden.
What really matters in health care expense containment is that everybody has timely access to treatments considered effective by the international scientific community. Every possible expense for further non-essential, ineffective or redundant treatments that individuals want to make for their health, their wellbeing, their contentment, their gratification, their serenity, their beliefs, should not engender any detriment to the funds allocated for essential treatments and universal health care coverage, and collected through compulsory contribution, imposed, one way or another, on everybody on the ground of solidarity, in order to achieve that primary goal. What matters is that further possible expenses do not put at jeopardy the feasibility and sustainability of the primary objective of guaranteeing everyone all those treatments to which they should be entitled. Once that goal is ensured, once the two fields and their funding sources are clearly separated, it should be held politically and economically irrelevant that single individuals decide to spend their own money on cosmetic surgery, alternative medicine, spas, wellness, pilgrimages to Lourdes or propitiatory rites. It should be as irrelevant as spending the same money in clothing, cars, popular exclusive intelligent or demential holidays, or whatever other consumer goods — including even lethal legal drugs such as tobacco and spirits, so long as the consequences of their use are not paid for by others.
The irresistible urge of a political class accustomed to playing the master (also) in the domain of health care, to superimpose their own whims above the assessments of the international scientific community, recently came to the fore once again. This time it was in the controversies against putting the RU-486 abortion pill on the Italian market, and the method of its administration which part of the political establishment would not only like to make more difficult and painful. They would also like to make it unnecessarily expensive (again at the expense of other health care needs being satisfied and other items of health care expenditure), by imposing with a political decision a mandatory hospitalisation that is not provided for by international medical protocols. A similar political meddling in medical proceedings was evidenced in the rebellion of some politicians against the abolition of prescription for post-coital contraception (“morning-after pill”). This has been a well-established practice for decades in Western Europe and beyond. In these cases the politicians involved were not supported by, nor were they able to stir up, any mass populist campaigns, but operated as a political wing of a powerful religious pressure group representing a clear minority in Italian society. Even in these controversies, however, politicians with no scientific or professional qualifications were ready to interfere, solely on behalf of their “democratic” legitimacy and representativeness, and not only with ideological or religious arguments, but also with allegedly “scientific” ones.
Even if it were possible to exclude such bizarre interference by a primitive national political establishment — perhaps just the forefront of a continental regressive trend, as has previously been the case in Italian history — the way back to a trusting reliance of “patient” citizens upon decisions taken paternalistically by “those who know more” would in any case be unworkable. This is not just because it would suppose that a general reliability and intellectual integrity of all operators might be taken for granted, starting with top political decision makers themselves (it would be naive in the first place to assume what all users should be convinced of). It would also be unworkable because two prerequisites have long disappeared: the indisputable supremacy of scientific knowledge and the univocality of ethical choices. Contemporary culture has, rightly or wrongly, irreversibly called into question, the epistemological foundation of the first assumption and irrevocably asserted the irreducibility and the full legitimacy of diverse ethical choices. This is also why all the recurrent recriminations against “do-it-yourself medicine” are bound to remain hopelessly ineffective. It is simply impossible to expect to solve problems through a simple reference to the principle of authority — if it were only the authority of a hypothetical pure science, capable, though it is not known how, of being detached from any compromise with industrial or political interests and from economic constraints. Rather, it would be useful, necessary and appropriate to engage doctors, researchers and journalists in health education, starting at school level.
Incidentally, although the argument obviously deserves much more than a passing reference, leaving greater room for individual self-determination and freedom of choice in health care, and releasing health care from the unlimited discretion of political rule does not necessarily imply running the risk of expenditure increases or unleashing the most irresponsible health consumerism (at taxpayers’ expense in a system almost entirely public, or, according to the approach hereby proposed, at their own expense). In some cases, indeed there may even be opposite effects.
This is particularly clear when, as unfortunately happens in Italy, sophisticated and very expensive medical treatments can be, and in fact are, imposed against the will of people unable to properly and validly express their consent at the very time when such treatments are carried out on their bodies but who had expressly refused their consent to such treatments in a living will drawn up when they were in full possession of their mental faculties. In a pluralistic society aggressive and futile care cannot be determined by political or supposedly “technical” standardized decisions that can be imposed on all by politicians. That would be nothing but an abuse and an act of violence on the part of politicians against the dignity and freedom of individuals. Political parties and parliamentary majorities will never realistically enforce such abuse on grounds of the ethical and philosophical assessments usually put forward, noble, albeit controversial, though they may be. Instead, as indeed has happened in Italy in recent years, it will be enforced only on the grounds of political, patronage related and electoral convenience, with a view to creating parliamentary and social alliances, gaining the support of pressure groups and organised active minorities, and so on. Only in very rare cases, through the work and authoritarian beliefs of a few minor politicians revealed to the more naive and traditionalist electorate as a decoy, will it have anything to do with their subjective good faith. Even in that event, however, it will be a case of political hybris, ideological arrogance, overbearing expressions of religious pride imposed as a compulsory lifestyle even on those opposed to them in their lifetime — or rather, imposed on others’ bodies against the express will of those individuals, by people long aware of no longer being able to convince their consciences.
In a pluralistic society it should be acknowledged that politics should have only the power to produce, with great care, a default solution, to be enforced in the absence of express individual decisions. Only the individual, however, can decide below which level of quality of life his/her continuing to live is not only no longer beneficial, but for him/her becomes a mere burden. A burden that usually not only entails unacceptable physical or psychological suffering and forced submission to a violent loss of individual dignity on the part of the individual personally concerned. It also means a huge economic waste of valuable health care resources, at the expense of the availability and timeliness of other treatments for the benefit of others. Rarely in these discussions, in fact, is this side of the issue even considered. Very often the intensive treatments needed to keep alive individuals whose will concerning the end of their life is ignored, are also extremely costly. In such cases, respecting individual self-determination would not only avoid offending the personal dignity of those concerned, but could also turn into a very tangible benefit for the health of others: a virtuous social, and even indirectly or unintentionally “altruistic” consequence of the respect for individual self-determination.
In any event, and whatever one’s opinion on social issues (i.e. those referred to in Italy as “controversial ethical issues”), the question of freedom of choice in health care goes well beyond the choice of doctors and hospitals. The flag in the struggle for “freedom of choice” in health care was initially raised in other countries on that very ground. In Italy, however, this problem is less acute than in countries where national health care services unlike in our case, allow users (or until recently allowed them) little or no personal choice in the matter, not even regarding their preferred medical doctors. The problem of freedom of choice concerns individual self-determination in a much broader sense, involving the pluralism of values inherent to contemporary Western societies.
It is perhaps no coincidence that some of the most ardent and knowledgeable Italian advocates of an entirely public and politically managed health care system, based their reflections on health care policies, and well beyond the complex technicalities of their specific subject, came to a passionate defence of communitarianism, understood as an overall principle of social organisation opposed to what they call “individualism”. Elsewhere I have tried to contribute to the elucidation of the different linguistic uses of this term in different national historical contexts and consequent misunderstandings. Here it is worth simply recalling the sinister meaning, resounding for a century in sociological reflections, of the idea of compulsory belonging to a “community” (Gemeinschaft), as opposed to the voluntary membership of a social organisation (Gesellschaft) based upon agreed and shared rules. It is also worthwhile objecting that, in plural societies like ours, expecting that a forced and all-absorbing communitarian cohesion might be artificially recreated can only produce social disintegration and, eventually, a segmentation of society into micro communities along ethnic, regional, cultural, generational or religious lines. Sometimes, it is only these, regrettably, that can, by fair means or foul, impose on themselves the social uniformity that it is no longer possible to enforce on society as a whole. The result is a number of opposing micro communities, in a struggle for hegemony or at least for a division of public resources, precariously co-existing until they feel able to overpower each other.
Perhaps the defence of communitarianism put forward by health care economics specialists might not fully take account of all the possible and sinister implications of such an approach. Or it might be an expedient not to have to acknowledge that it is actually the political class that again has the last word in every publicly ruled health care system, they being the ones, in the end, entitled to express the binding will of the “community”. In the current cultural climate, in Italy as well as elsewhere, “community”, to many, could perhaps seem a less compromised and more acceptable word than “political class” or “parties”, or sound — what it is not — gentler, more inoffensive and amiable. But claiming that it should be the task of “the community to define what health is”16 — “health”, note, not just “health care” — is a very demanding application indeed of a quite radical brand of communitarianism that may sound threatening to critical and free spirits.
Increasingly, across Europe, communitarianism is the political theory opposed not only to the brand of individualism interpreted as a barely diluted form of social selfishness (rather than, as would be historically more correct, as the attempt to defend the individual and his/her critical autonomy from uniformity and standardisation). but it is also opposed to the liberal and democratic idea that the foundations of a free society should be the respect for individual liberty, for the rule of law and the voluntary consent of citizens to the constitutional covenant, rather than a forced homogeneity of values imposed on society by binding political orders. Consent to the constitutional covenant is itself the expression of a choice of values, significant if minimal, that according to democratic liberalism should be generally shared. However communitarians demand much more. Homogeneity is often required as a product of universal faithfulness, that, it is claimed, must be natural and spontaneous, to the “roots” and ancestral values held to be the only possible foundation of genuine and cohesive social bonds. Such roots are nowadays, and in some cases have for centuries been alien to the personal cultural and family heritage of many members of our societies. To opponents who resist social compulsory homogeneity, who do not find it spontaneous and natural at all to adapt, it seems communitarians demand that they bow to the lifestyles and values imposed on society by political majorities. Perhaps it is not entirely a coincidence that the country that found what is in our view such a virtuous balance between the demands for equity and social solidarity and individual self-determination in its health care system is also one of the few to have also regulated for active voluntary euthanasia.
To return in conclusion to the more limited scope of the reform of health care policies, the crucial point of this reflection is that it is not a matter of making private management of health care the object of the same uncritical trust that has mostly disappeared, and for well-founded reasons, in political management. It is a matter of taking the distinctive character of health care economics seriously. It is worthwhile, therefore evaluating the possibility of extending to other countries a system, already successfully tested to some extent, and no less universalistic than those currently enforced elsewhere in Europe. This is a system in which both buyers and providers of health care services are encouraged to pursue an independent economic self-interest to contain health care costs, while at the same time being forced to compete in quality and effectiveness of treatments and customer satisfaction. It is a system in which the political establishment and the civil service continue to act as regulators and controllers, but no longer directly manage health care (let alone act as citizens’ spiritual directors). They are therefore, as far as possible, prevented from the possibility of making illegal economic or electoral profits out of insoluble conflicts of interest — so that the only hope for improving the ethical quality and fairness of their behaviour is not placed in their miraculous collective repentance and conversion. It is a system in which the increase in health care costs, to some extent inevitable in the coming decades as a result of demographic change and technological advances, cannot put an additional burden on public finance causing further imbalances, bound eventually to lead to a redistribution of wealth to the benefit of recipients of financial income on government securities, thus largely frustrating, if not reversing, the actual equitable or redistributive intent of all welfare policies.
From the liberal point of view of the author of these lines, the Dutch reform has also the not unimportant merit of once again recalling that the free market is not purely a synonym for laissez faire, and that unlimited laissez faire is no synonym for liberalism.
We should be realistic enough not to be under any illusions. In Italy we would have to be on the brink of a final and irreparable financial collapse of the entire system before we could persuade politicians and vested interests pressure groups to give up. Nonetheless the task of this article is to put up for discussion, perhaps even for a future debate, solutions that politicians — and above all politicians, on average of the lowest level in Europe such as the Italians, mostly demagogues and outlaws or inept followers of opinion polls, rather than responsible leaders — do not have the strength or the will to address until inescapably obliged by the coercive force of events17. In this case these will be the decreasing sustainability of the current health care system’s costs over time and the political impossibility of continuing to conceal beyond a certain limit the inevitable reduction of the effective availability of health care services.

16 Paolo Vineis, Nerina Dirindin, In Buona salute. Dieci argomenti per difendere la sanità pubblica, Torino, Einaudi, 2004, p.76.
17 The Dutch reform was first presented to the attention of the Italian public in November 2008, at the international conference “Per una politica sanitaria europea / Health Care Policy and Fundamental Rights in Europe”, organised in Rome by the European Liberal Forum with the support of the Critica liberale foundation. The proceedings have been edited in English by Beatrice Rangoni Machiavelli and Francesco Velo, Brussels, European Liberal Forum, 2009. See also Giampaolo Galli, Ci può essere un futuro per un sistema sanitario universale e responsabile, in Le riforme che mancano, cit., p. 245.

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