The Fears of the Rich, the Needs of the Poor by William W. Foege

Author:William W. Foege
Language: eng
Format: epub
Publisher: Johns Hopkins University Press

a The story of the impact on global health that this small group grew to have is told in my upcoming book on the history of the Task Force for Child Survival.

chapter 16

DO NO HARM

The ethical problems encountered in public health span the spectrum of those seen in clinical medicine, but they have additional ramifications. The oft-repeated admonition First Do No Harm, heard throughout the years of medical training, usually referred to errors of commission. Even when the Institute of Medicine published a book on medical mistakes, it concentrated on such errors (1).

But when Wolf Bulle told me, as I left for Africa in 1965, “You will never forget the people you kill,” it caused me to wrestle with that concept.

Errors of Omission

It soon became clear that we will, of course, not know most of the people we kill. Far more people die and suffer because of our errors of omission. The science not used, the science not shared, the vaccines not given, and the prevention not practiced, the Medicaid not expanded, the millions without health insurance, all cause harm but are rarely mentioned or even recognized in the context of First Do No Harm. Because the price of those omissions is usually not seen, it is often discounted.

Medical care today makes it difficult for the busy practitioner to discuss prevention with patients. Most insurance plans do not adequately compensate practitioners for time spent giving prevention advice. A half-century ago, people were worried about socialized medicine without understanding that capitalism would soon take over medical care in the United States. Now profit drives the system, and because of that, it is possible to violate the First Do No Harm dictate repeatedly each day. It is as if we were told in school to do no harm unless money is involved.

We stand embarrassed to spend more per capita on health care than any other country; yet, we cannot match the health outcomes of the top twenty countries around the world. We proudly promote the marketplace as the way to deliver health care without acknowledging that the vast majority of those countries have single-payer systems. Are we interested in promoting the marketplace or promoting health? And isn’t the burden on us to show that the marketplace can do better rather than continuing to just say it?

The way out of this ethical dilemma is to have a single-payer system in which all are treated equally and health results become the standard for measurement. At present, the marketplace pays for process rather than outcome, and prevention is not a billable commodity. In the single-payer system, payments could highlight results in terms of morbidity and mortality. Results cannot always be measured for individual patients, but aggregate results can point out which programs should receive financial rewards.

This problem is not limited to medicine. The people for whom we vote make decisions on food stamps, medical coverage, education support, and research appropriations. When they vote not to provide early education, medical care, prevention, or Medicaid expansion, we as voters kill through errors of omission.

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