Inquiry

In all candor, I think the sober perspective is that the national debate raging currently is NOT about Integral healthcare at all.   An integral approach would consider, above all, honest discourse and an attempt to find the common language so we can begin a discussion.  For example, consider the common argument centering around 47 million Americans who either don't have healthcare access or don't have health insurance.  Which is accurate? Perhaps they don't have affordable insurance.  Perhaps many choose to decline insurance over cost.  Others claim many are illegal aliens and can't legitimately participate.  Then there's the argument that 80 percent of Americans don't want radical changes to our  healthcare.   This is a democratic republic.  Pick your politics and the argument's core varies. 

As someone who has worked in emergency healthcare for some time, I've yet seen anyone with access to a hospital (that may be a legitimate discussion point) denied care.  And that includes Intensive Care Units. We in the West have a poor concept of a personal continuum of healthful living, which is, I believe, directly attributable to the trends in wellness (or lack thereof) across the U.S. 

In all truth, the U.S. system has allowed phenomenal innovation in development of medications, surgical interventions and preventive programs.  Costs are an issue.  But discarding systems that also have led to such innovations would not be integral.  Forget a truly socialized system.  It won't work for the very young or the very old or the extremely ill.  Discarding those factors in our population distribution can't be integral.

No, this debate is about a cultural war.  The green among us insisting their flat-earth mentality is good for all.  The orange blindly suspicious of anything beyond the norm.   This debate is draped in a healthcare facade hiding fear of the next stage in the evolution of this republic.  Consider that great nations, historically, have a good 200 year run before trouble  begins.  The U.S. is now in a boomerang trajectory post-9/11.  Deny obvious threats externally by focusing internally at the peak of national fatigue.  Students of history will recall this happening early in the 20th century.  Groundhog day?

So what exactly do we want to truly do to improve and more fully integrate our relatively (compared internationally) healthcare system?  Costs are an issue.  There are truly a number (to be determined, but real nonetheless) out there who are caught without adequate healthcare in rural areas and areas of urban blight and violence.  Socialized medicine won't fix those.  Education, leadership, governance, compassion, candor are a good start.

The current healthcare reform debate is primarily focused on lower right quad "problems", specifically reducing the number of Americans who lack health insurance and reducing the costs of providing health care. When you consider healthcare as a process, it is sandwiched between an upstream set of values/beliefs/premises (all left sided) and a set of downstream outcomes primarily right sided). So, for example, if the value/belief/premise is that every American should have health insurance, then health care must be engineered in order to achieve this outcome.

Many of the beliefs/values/premises are not part of the current debate. In my judgment, this is where the healthcare debate should start. We should be discussing and debating what does health mean? What is the responsibility of an individual (upper) and what is the role of government/health insurer/employer (lower) in helping to achieve health? Is it acceptable for an individual to be irresponsible when it comes to their own health (e.g. by smoking and drinking to excess and having poor health habits) and expect society to bear the cost of caring for this indiscretion? Why do we as a culture and society have a healthcare system which is based on disease and not on wellness? Is the current scientific reductionism (all upper right) which pervades the Western medicine approach the best way to promote and pay for healthcare? Do we want a system built on a solid foundation of primary care or do we want to continue with a costly subspecialist weighted system? Is an 8 minute average encounter time with your PCP acceptable? Where does CAM fit in? Is it acceptable for the insurance industry and the pharmaceutical industry to have the amount of influence they currently enjoy in shaping our current approach to healthcare? If most Americans want a single payer system, why do we permit our elected officials to craft something else?

Once we have decided the answers to these upstream questions, then we can decide what outcomes we want given the restrictions of limited resources and competing demands. After the upstream values/belifs/premises are explored and the desired outcomes are agreed upon, then the remaining task is to engineer a healthcare system based on these values etc. in order to achieve the desired outcomes.

An Integral contribution to the current debate would call attention to the individual vs. collective issues and the objective vs. subjective issues which are all at play simultaneously. Minimally it would expose the strong bias on the upper right quad in our current approach to medical care and it would expose the shallowness of the reform efforts as focusing on systems (lower right) issues while ignoring the entire 2 left quadrants.

Excellent comments so far. I also believe that at least part of the health care reform puzzle will be a mature Integral Methodological Pluralistic approach to “Evidence Based Medicine”. While it is absolutely essential to emphasize the need for prevention and well-being in all quadrants and all levels, it is also true that all humans must start at level 1 and evolve in a world exposed to potentially injurious forces in all quadrants so we can’t let go of the “disease management” model entirely; shit happens.

Evidence Based Medicine (EBM) is an extremely influential movement within conventional health care. When understood and utilized appropriately it can significantly improve both the diagnosis and therapy of patients leading to improved patient outcomes. Through its relentless appeal to a “hierarchy of evidence” it has also been the main factor in reducing the potential for systematic bias introduced by large pharmaceutical companies (or other special interest groups) in medical research. Unfortunately however, although EBM recognizes the importance of system factors, patient values, and cultural expectations it is not as strong at articulating how to assess evidence in these areas. In fact, the term “evidence” itself is often used to mean empiric evidence only.

Integral Methodological Pluralism (IMP) offers a potential solution to this limitation of EBM. An IMP informed EBM would recognize evidence from all 8 zones and the “hierarchy of evidence” would exist within zones and not across zones. An IMP informed EBM would also provide a framework, language, and methodologies to more clearly understand and articulate the role and impact of patient/cultural values and perspectives, as well as the health care provider’s values and perspectives with regards to clinical decision making.

Implications of IMP to EBM: let’s return then to the first principle of EBM: “In clinical decision making, evidence is never enough”. What this means is that whatever the (empiric) evidence, the values and preferences of both the clinician and the patient must be considered and interpreted prior to making a clinical decision. However, evidence can be generated in all 8 zones so “values and preferences” can be more clearly defined and interpreted. While the empiric zone should not be marginalized in an Integral Health Care model, nor should it be privileged. Phenomenology, Structuralism, and Hermeneutics for example, have much to teach us about how to practice medicine.

With regards to the second principle of EBM “There is a “Hierarchy of Evidence”, again, IMP can improve the classical EBM teaching. The vital aspect of this “hierarchy of evidence” in an IMP informed EBM is that the gradation of evidence is not cross-zone but within zone. That is, zone 6 is not better than zone 2, which is not better than zone 1, etc. Each clinical question is best answered with methodologies specific to the zone of the injunction. No question is marginalized, and no zone is privileged. A hierarchy exists within a specific zone though. For example empirical studies that control for observations that may be significantly altered by bias, chance, or confounders are better than evidence gained from poorly designed studies or anecdote. Likewise, however, “good evidence” is sought for diagnosis and therapies that don’t lend themselves to empirical study. In short, an IMP informed EBM has the potential to legitimize diagnosis and therapies based in all 4 quadrants with evidence from all 8 zones, likely including things that have been previously marginalized by conventional medicine. The corollary, however, is that “alternative” diagnosis and therapies seeking legitimization must meet the threshold for acceptable evidence by a peer reviewed community of experts. Zone 6 or Empiricism, however, does not have a monopoly on rigourous methodology.

We can see how an UR diagnosis only might commit a patient to expensive, quantity of life extending, but quality of life eroding therapies. On the other hand, a LR diagnosis focused system manager, might withhold reasonable patient valued treatment options under the mantra of cost effectiveness. Only a diagnostic process aiming for the “sweet spot” where all quadrant interests are met will lead to therapies which are truly evidence based and integral.

After the correct (all quadrants) diagnosis is made the best therapy for a patient is based upon the “outcomes literature”, ie research that determines the effect of therapeutic interventions on outcomes. One classification of outcomes commonly taught in EBM is “the 6 D’s”: trying to avoid Death, Disease, Disability, Discomfort, Dissatisfaction, and Destitution. These D’s are more clearly defined as Death = mortality directly attributable to the condition, Disease = objectively measurable signs of altered physiology or anatomy, Disability = A change in the functional status of the patient in terms of ability to live independently, Discomfort = uncomfortable symptoms such as pain, nausea, vertigo, shortness of breath, or depression, Dissatisfaction = expectations of patients and families are met by services provided, and Destitution = the financial consequences of health care to the patient and society.

An IMP framework for the study of outcomes important to EBM might look something like this where (for the purposes of simplicity initially) three of these outcomes end up in the UR quadrant with one each then being situated mainly in the other three quadrants (although all "tetra-arise"):

Upper Left

• Discomfort: In any line or level as described by zone 1/2 studies. 

Upper Right

• Death: as measured by zone 5/6 studies
• Disease: as measured by zone 5/6 studies
• Disability: as measured by zone 5/6 studies

Lower Left

• Dissatisfaction: In relation to cultural expectations or values as evaluated by zone 3/4 studies.

Lower Right

• Destitution: Cost – effectiveness as measured by zone 7/ 8 studies.

Obviously, there could be a limitless number of outcomes relevant to each quadrant in a mature and developed IMP informed EBM but the classic 6 D’s is a good place to start. The essential point is that these outcomes can be evaluated with zone appropriate but rigorous methodologies.

To paraphrase Albert Einstein who said: science without religion is lame, religion without science is blind, it could be said as we move towards a more Integral model of Health Care that: EBM without IMP is lame, IMP (in the context of health care) without EBM is blind – and not likely to succeed.

I am a Canadian with government sponsored healthcare. It's universal.  Three weeks ago, I had a potentially serious eye problem. I went to the ER, saw a doctor within three hours (a triage nurse had assessed me quickly) who thought I needed to see a eye doctor.

He made the appointment for me and I saw the second doctor, the next morning ( Saturday) at 9;00 am. I was ok.  The costs for these services? My healthcard provided by my provincial government. Great service, no waiting, no cost.

Canada's commitment to universal health care also had a rough ride many decades ago when it was first introduced. Some doctors and lobbyists were dead against it. But a courageous provincial governement (Saskatchewan) kept at it until it was passed. Other provincial governments and the federal government followed suit.  Now, it's one of one greatest resources. Yes our taxes are probably higher than yours, but we never have to worry about getting imperfect but generally very good health care whether or not we are working, whether or not we have money.  We choose our doctors and they make the medical calls.

So keep working at achieving this truly remarkable objective. All of you deserve it!

 I have a very basic question. Is it possible to raise the level of goodness in a society via coercion...?  

Most people in America agree that having access to affordable healthcare is a desirable thing, but differ substantially on what makes healthcare more expensive and what makes it more affordable. If people are coerced via punitive taxation and the threat of prison to participate in a program that they personally find objectionable, has not their agency been violated...? 

Person A may well receive a doctor visit, but Person B feels robbed by Person C, and Person C committed an act of aggression against Person B.  Some will assume that Person A's need to see a doctor outweighs Person B's agency, but Person B may well value his agency more than his own life. Person C has relegated himself to a level of ethnocentric aggression against those he deems deserving of his punishment. 

It seems to me that well-intended but coercive social programs merely move badness around to others -- and the net level of badness actually increases.  It don't see this as an effective means of raising a society to a higher stage of moral development. 

Universal care is about caring for ALL, is it not, including caring for those who find current health care reform proposals to be immoral and objectionable...?