My Wednesday reflection on service and my recent experience in the ER (from both sides of the curtain) got me thinking about pain.

Simply put my job as a physician can be boiled down to two primary objectives – 1. To treat treat/cure disease, and 2. To alleviate suffering. And, of course, in the application of each of these there is the ever present imperative to “benefit and yet not to harm.” Based on my observations thus far, there are three primary reasons people come to the ER – 1. They come for treatment, 2. They come for reassurance, 3. They come for pain pills.

PAIN PILLS: THE BANE OF AN ER PHYSICIAN’S EXISTENCE

It sucks to feel used, it is no fun to be lied to. It sucks to be in pain, it is no fun to be ignored. And thus the conflict that gets played out hundreds, nay thousands of times in American emergency rooms each day. The classic dilemma of distinguishing between those who are “drug seeking” and those who are in “real pain,” begs any number of questions. Who is to say they are different people? Whose right is it to determine or judge the level of pain another individual is experiencing? Is all pain bad? Does pain always need to be treated? Are narcotics over-used? Are narcotics under-used? Is it a doctor’s job to relieve patients of all pain and at what cost?

These questions and more have led me to a broader reflection on the meaning of pain in our culture. What follows is a collection of scenarios, quotes, and common sayings related to or inspired by pain. I am curious to hear what the topic brings up for you.

• “No pain, no gain.”

• Narcotics: Illegal, Prescribed, Controlled, Addictive, Pain-alleviating, Sleep-inducing, Potentially-lethal, Expected.

• The brand name of prescription narcotics and muscle relaxants are also household names: Vicodin, Percocet, Flexeril.

• Most people I know have been prescribed a narcotic for one reason or another at one point on their life.

• The juxtaposition of a sweating writhing man passing a kidney stone rating his pain at a 6-7/10 and a young woman with a sprained ankle resting comfortably in bed rating it at a 10/10 and demanding narcotics.

• “A lot of people run a race to see who is fastest. I run to see who has the most guts, who can punish himself into an exhausting pace, and then at the end, punish himself even more.” -Prefontaine

• An elderly woman is dying. Her disease causes her severe pain even at rest and makes her feel as though she is suffocating. Morphine could help alleviate both, but she refusing saying, “I don’t want to get addicted.”

• The husband of a young woman with chronic headaches threatens to kill an ER physician for not giving his wife more Dilaudid stating,”You are obligated to treat her pain.”

• “Cutters” – inflicting physical pain on themselves to relieve existential, emotional, psychological distress.

Merely the body’s messenger of injury and imbalance?

Perhaps a villian to be slayed at all costs?

Or is it a virtue to be endured and even relished?

Discuss.

This debate regarding the ‘how to’ for America’s healthcare system has one question at its center. Is healthcare a commodity? As suggested in my previous blog: “the simple answer is that it’s a right to the extent that we can afford it, and it’s a commodity to extent that we can’t.”

This is the most fundamental hermeneutic that a capitalist nation can use to tease out the nature of the unalienable rights as declared unanimously by the founders of this country. It’s been eight years since these so called unalienable rights have been taken seriously, so perhaps it is worth the time to quote them here: “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”

It becomes necessary to ask a follow up question at this point: insofar as healthcare is a right, how is it that this right is left in the hands of private sector? Surely, the private sector has every right to provide access to healthcare for the sake of profit. But just as surely, profit cannot be allowed to function as the guarantor of rights accorded by the United States of America. Ken Terry tackles the issue of private vs public sector on his blog where he quotes Obama as saying: “If private insurers say that the marketplace provides the best quality health care … then why is it that the government, which they say can’t run anything, suddenly is going to drive them out of business?”

What is needed to help focus this conversation is a refresher on the principal of Emergent Socialism. As stated in the prior blog: “Let the principle of the ’social’ guide what we decide to declare worthy of our subsidization. Let’s not be afraid to socialize what inherently lends itself to socialization, and let’s not be afraid to pull the plug on things that are not inherently social.”

Rights like life and liberty are inherently social. If they are to be guaranteed as rights, they cannot be left willy nilly to the private sector whose duty is not to serve and protect, but to circulate capital. There are, of course, elements of the healthcare system that do not fall under the public interest. There are also aspects of it that are beyond the capacity of the government to guarantee. Beyond these points, healthcare is a commodity not a right.

What remains then is not to argue over socialism vs free market, or Republican vs Democrat,–but rather determine to the best of our ability where do draw the lines between right and commodity. It is here, at this most fundamental level, that we can avoid the petty spin zone that has taken over American politics, and get back to the business of our civic duty.

According to the NCHC, in 2007, health care spending in the United States reached $2.3 trillion. That’s $7600 per person. We spend roughly 16 percent of our GDP on healthcare. Other notables, Swizterland, Germany, and Canada spend 10 percent or less, and somehow we manage to leave almost 47 million Americans uninsured. This is what healthcare looks like when it is treated inappropriately as a true commodity. Inflated costs, incredible waste, and the best possible doctors/procedures for the privileged few that can afford it.

The neo-capitalist would call this a success. “We have the best doctors and the best equipment in the world,” they would say. This has been the measure of healthcare, never taking into account accessibility or affordability of healthcare as a service. It is a broken system. Easy to criticize, I know, but I’m about to offer a solution.

It hinges on analyzing two aspects of the nature of healthcare: human need/right and commoditization.

First, healthcare is a basic human need, but can we call it a right? And second, to what extent is healthcare a commodity?

The simple answer is that it’s a right to the extent that we can afford it, and it’s a commodity to extent that we can’t. This means treating healthcare as such. We begin by setting up a tiered system for healthcare. The first tier is preventative care, simple procedures, general doctors vists, etc. In this scheme the government subsidizes the entire first tier. Not only does this limit what private providers have to cover, it ensures access to preventative medicine for every American reducing the overall strain on the system. Second and third tier (expensive, elective, and experimental procedures) can then be parsed out among private insurance companies dramatically reducing insurance premiums.

What remains is a not insignificant debate over what fits into the tiers and how to rebuild the existing infrastructure to accommodate the expansion of preventative care. By tiering our healthcare system we can begin to treat the citizens of the United States ethically and responsibly. It’s the first step of a long journey to realize the potential of the American dream.