Bandy X. Lee, M.D.
*Primum non nocere*, to first do no harm, is the unchanging foundation for Hippocratic medical ethics. Each generation must, nevertheless, redefine what “doing no harm” means for its time. As we are making historic transitions in healthcare in the U.S., now is such a time for our generation.
“Doing no harm” means first avoiding doing the most extreme harm—that is, violence. Meanwhile, it is important to note that our understanding of what constitutes violence has also been expanding: the multi-determined nature of violence, no matter the scale, point to causal dynamics beyond the immediately apparent. The greatest predictor for interpersonal violence levels, for instance, turns out to be societal inequities in income and wealth. The rate of wars at a global scale similarly parallels increases in disparities between rich nations and poor nations. Even suicide, or self-directed violence, appears more socially determined as we see how it increases with unemployment.
However, the deaths and disabilities resulting from all suicides, homicides, and wars pale in comparison to the excess deaths and disabilities arising from structural violence. Structural violence operates through unjust social structures or institutions, such as the denial of healthcare to certain segments of the population. Advances in preventive medicine, additionally, equip and oblige the physician to prevent illness and injury before they occur, and not just treatment after the fact. Preventing these excess deaths and disabilities by ensuring just distribution of healthcare has, therefore, become an important imperative for physicians in the task of avoiding further violence.
The uninsured are generally those who lack a voice in society, but this holds especially true for the mentally ill and uninsured, who often also grapple with a tragic effect of mental illness: believing that one is not ill and actively avoiding care. Knowledge about this nature of mental illness compels physicians to advocate for adequate care such that few individuals fall to this level of illness to start with, and to protect them from harm to self or others when they do.
In this day when concern for mentally ill individuals is particularly scarce (resources for their care have dwindled to pre-industrial levels, while punishment for their “misbehavior” correspondingly maximized), physicians need to be their active advocates. The truth is that behind every Adam Lanza—who was responsible for the Sandy Hook Elementary School massacre in Newtown, Connecticut—there is a growing number of mentally ill individuals languishing undetected in jails, prisons, homes, and the streets, the numbers growing with each reduction in budget. All the security measures in the world, including keeping every mentally ill individual from obtaining guns, will not prevent massacres the way universal care would.
It is basic knowledge that early and comprehensive prevention, before anyone gets ill, saves money in the long run and prevents great suffering, illness, and death in the process. That profit is the main motive for maintaining the high-expenditure, inefficient status quo is no secret: healthcare is the biggest industry in our nation, absorbing almost one-fifth of our gross domestic product, of which administrative costs are almost one-third, with CEO compensation running up to 50 million—despite consistently poor outcomes. Since a major World Health Organization study found in 2000 that the U.S. health system ranked 37 out of 191 countries in performance, numerous studies have replicated the results: we rank last or next-to-last among all countries examined in every study. It is about time that we join the 32 other developed nations and growing number of developing nations in providing truly universal healthcare—and not in diluted form intended to appease industry.
For this to happen, physicians may need to lead the way. A couple more steps may have to happen beyond Obamacare, but let us allow for the process sooner rather than later: the sooner it happens, the more lives it will save. We as physicians must include in our roles educating the public about the benefits of living in a healthy society. We must convince ourselves and then others that this is a good thing for our country. Then, and only then, might we collectively become healthy enough to recognize the advantages of choosing universal healthcare in the first place.