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    The American Health Care Delivery System

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    Robert Frost (1874 -1963), an American poet wrote the following lines:

    I shall be telling this with a sigh
    Somewhere ages and ages hence;
    Two roads diverged in a wood, and I
    I took the one less traveled by,
    And that has made all the difference.

    There are two cults (options) within the traditions of ancient Greece - Aesculapius and Hygeia - which dealt with health care delivery. Aesculapius was a strict patient and health care provider model that was aggressively centered around the patient, whereas Hygeia was a public health model that focused on prevention in the context of public interest. It is clear that American medical care is built on the Aesculpapian model. When one considers our concerns regarding the allocation of health care, is it possible that some of our problems are associated with this choice made over 1,000 years ago? Consider how the debate would be altered had we taken the Hygeia model (option) as the standard of health care provision.

    In particular, address each of the following:

    1. What would the health care system look like?
    2. What would be its primary legal, ethical, and moral obligations and why?
    3. What would be among the problems facing this different model of health care?
    4. What lessons, from this model, can you take into your own healthcare practice and/or values and why?

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    You have asked for an opinion-based response to the argument of a preventative vs non-preventative health care system adressing four particualr questions. The poem below and the analysis that follows present a clear picture of the dilemma that has faced healthcare delivery in the past and continues to be faced today.

    The Ambulance Down in the Valley

    'Twas a dangerous cliff, as they frankly confessed,
    Though to walk near its crest was so pleasant;
    But over its terrible edge there had slipped
    A duke and full many a peasant.
    So the people said something would have to be done,
    But their projects did not all tally;
    Some said, "Put a fence 'round the edge of the cliff;"
    Some, " Put an ambulance down in the valley".

    Well, the cry for the ambulance carried the day,
    For it spread through the neighboring city;
    A fence may be useful or not, so they say,
    But each heart became brimful of pity
    For those who have slipped over the dangerous cliff;
    And dwellers on highway and in alley,
    Gave pound and pence, not to put up a fence,
    But an ambulance down in the valley.

    "For the cliff is all right, if you're careful," they said
    "And even if folks slip and are dropping,
    It isn't the slip that hurts them so much
    As the shock down below when they're stopping".
    So day after day, as those mishaps occurred,
    Quick forth would the rescuers sally
    To pick up the victims who fell off the cliff
    With their ambulance down in the valley.

    Then an old sage remarked, "'Tis a marvel to me
    That people give far more attention
    To repairing results than to stopping the cause,
    When they'd much better aim at prevention".
    "Let us stop at the source of this mischief" cried he,
    "Come neighbors and friends, let us rally,
    If the cliff we would fence, we could almost dispense
    With the ambulance down in the valley".

    "Oh, he's a fanatic", the others rejoined;
    "Dispense with the ambulance? Never!
    He'd dispense with all charity, too, if he could,
    No! No! We'll support them forever.
    Aren't we picking up people as fast as they fall?
    Shall this man dictate to us - shall he?
    Why should people with sense stop to put up a fence
    While an ambulance waits in the valley?"

    Source: (Joseph Malines, published in Journal of Primary Prevention, 10 (1) Fall 1989 pp. 63-64 with comments by Joseph Galano who added another verse to the poem which focuses on empowerment as the ultimate prevention strategy).

    Reclaiming Our Health: Fences Again
    by John Robbins

    Once upon a time there was a large and rich country where people kept falling over a steep cliff. They'd fall to the bottom and be injured, sometimes quite seriously, and many of them died. The nation's medical establishment responded to the situation by positioning, at the base of the cliff, the most sophisticated and expensive ambulance fleet ever developed, which would immediately rush those who had fallen to modern hospitals that were equipped with the latest technological wizardry. No expense was too great, they said, when people's health was at stake.
    Now it happened that it occurred to certain people that another possibility would be to erect a fence at the top of the cliff. When they voiced the idea, however, they found themselves ignored. The ambulance drivers were not particularly keen on the idea, nor were the people who manufactured the ambulances, nor those who made their living and enjoyed prestige in the hospital industry. The medical authorities explained patiently that the problem was far more complex than people realized, that while building a fence might seem like an interesting idea it was actually far from practical, and that health was too important to be left in the hands of people [carpenters] who were not [medical] experts. Leave it to us, they said, for with enough money we will soon be able to genetically engineer people who do not bruise or become injured from such falls.
    So no fences were built, and as time passed this nation found itself spending an ever-increasing amount of its financial resources on hospitals and high-tech medical equipment. In fact, it came to spend far more money on medical services than any nation had ever done in the history of the world. Money that could have gone to community services, decent housing, education, and good food was not available to the people, for it was being spent on ambulances and hospitals. As the cost of treating people kept rising, growing numbers of people could not afford medical care...
    The more people ...

    Solution Summary

    This solution offers an opinion-based response to the argument of a preventative vs non-preventative health care system adressing four particualr questions.