When funding healthcare, don’t forget the caring bit

It’s Easter, and we’ve got the day off. So let’s think about something different. As a community, we spend a fortune each year on health, mainly through governments. What has economics got to tell us about healthcare? And, since it’s Easter, what light has Christianity got to shed on how we fund healthcare?

One man who’s thought deeply on these questions is Dr Stephen Duckett, Australia’s leading health economist, whose career has included academia, running government health departments, and the Grattan Institute think tank. He’s now back in academia, at the University of Melbourne.

Since there’s never enough money to spend on healthcare, hard decisions have to be made about what can be done and what can’t.Credit: Michel O'Sullivan

Duckett has long been a lay reader in the Anglican Church. He’s recently completed a doctorate in theology, awarded by the Archbishop of Canterbury. He’s turned his thesis into a book, Healthcare Funding and Christian Ethics, published by Cambridge University Press.

One way to run a hospital is to let the doctors and nurses do as they see fit until the money runs out but, for several decades, health economists’ advice has reshaped the health system, helping to ensure that the money available is spent in ways that do the most good to patients.

One definition of economics is that it’s the study of scarcity. We have infinite wants, but limited resources of land, labour and physical capital to achieve those wants. So we must carefully weigh the costs and benefits of the many things we’d like, so we end up choosing the particular combination of things that yields us the greatest “utility” (benefit) available.

Stephen Duckett, whose career has included running government health departments, is now at the University of Melbourne.

Since there’s never enough money to spend on healthcare, hard decisions have to be made about what can be done and what can’t, what drugs should be subsidised and what can’t, who should be helped and who turned away.

Health economists analyse the cost-effectiveness of the various options to help governments and hospitals make their choices, working out the number of “quality-adjusted life years” each option would add.

The Scotsman called the father of modern economics, Adam Smith, saw it as a moral science but, as economists have striven to be more “rigorous” (which mainly means more mathematical) this touchy-feely stuff has fallen away.

Most economists see economics as amoral, that is neither moral nor immoral; having nothing to say about moral issues. When it comes to means and ends, economists see themselves as sticking to means.

They’re saying: tell me what you want to do, and I’ll tell you the best way to achieve it. That’s what they say; it’s not always what they do.

Healthcare is an amoral proposition, according to economists.Credit: Ricky Blank

Economics is based on utilitarianism: seeking the greatest good for the greatest number. But this ignores the question of “equity”: how fairly the benefits are shared. Are some getting a lot while others miss out?

Duckett says: “Economics’ assumption that humans are simply individual units, de-emphasising community, and [economics’] ubiquitous use in policymaking, comes at a cost, as Homo economicus [the self-interested, rational calculator that economists assume us to be] crowds out other manifestations of what it is to be human.”

Economists often say they have no expertise on equity and the community, so they leave that to others – such as the politicians. Economists often claim that economics is “objective” and “value-free”.

But Duckett says it’s not simple. By ignoring issues you’re implying that they don’t matter. And you’re making implicit assumptions that are value-laden.

For instance, if a cost-effectiveness study does not explicitly highlight the distribution of costs and benefits [how unequally they are shared between people], it is implicitly conveying the message that the distribution is not a relevant issue.

If nursing home funding allows money ostensibly allocated for care to be leached out as extra returns to the owners, then quality is assumed to be not a concern of those doing the funding.

If a system design places a higher monetary reward on cosmetic surgery intended solely to improve appearance compared to the monetary reward for caring for older patients and people with mental illness, this sends a signal about the value placed on care for the marginalised.

Duckett says that, because decisions about public policy inherently involve value choices, health economics becomes a “moral science” whether economists like it or not. What’s true, however, is that economics is not well-equipped to determine issues such as what should be society’s priorities, what value should be place on unfettered choice, and the value to place on ensuring no one is left behind.

Should Christian ethics be a factor in public policy?Credit: Darrian Traynor

This is where Christian ethics has a contribution to make, a contribution that, except on matters of sexual morality, doesn’t differ much from the views of the aggressively secular philosopher Professor Peter Singer and, no doubt, many other Western ethicists.

Duckett offers a “theology of healthcare funding” based on Christ’s parable of the Good Samaritan. As I hope you remember, a man was travelling to Jericho when he was set upon by robbers, who left him naked and bleeding by the road.

Two separate religious figures passed by him on the road without stopping to help. But a Samaritan saw him and “was moved with pity”. He bandaged his wounds, put him on his donkey and took him to an inn, where he paid the innkeeper in advance to look after him, promising to come back and pay for any extra expense.

From this parable Duckett derives three principles that should guide health economists in the advice they give on healthcare funding.

Compassion … must involve helping people other than yourself. So health economics must be less impersonal.

The three are: compassion (shown by the behaviour of the Samaritan), social justice (everyone included and treated equally; shown by the identity of the Samaritan, a race despised by the Jews) and stewardship (shown by the innkeeper, who was trusted to care for the traveller and to spend the Samaritan’s money wisely).

Compassion must involve feeling leading to doing. It must involve helping people other than yourself. So health economics must be less impersonal, remembering the flesh and blood behind the statistics and calculations. Any funding arrangement must allow time for workers to care for patients in a compassionate way.

The Christian ethic is that social justice is not simply about fairness for atomised individuals, but also the person as part of a community, something economists tend to forget. Archbishop Desmond Tutu has said “a person is a person through other people . . . I am human because I belong. I participate, I share.”

Archbishop and Nobel laureate Desmond Tutu in 1993.Credit: AP

“Christian contributions to the public square need to challenge policy ‘solutions’ that rely on individuals pulling themselves up by their own bootstraps, victim-blaming approaches, and a narrow definition of [who is my] ‘neighbour’,” Duckett says.

As for stewardship, it’s the easy bit. It’s the Christian word for what economists already know about: making sure that other people’s money is spent carefully, and their property is looked after. It’s being efficient.

But the Christian contribution to what health economists do is to make sure stewardship is kept in tension with the other two principles. “Austerity does not mean that compassion and social justice can be ignored, or distributional consequences [for the rich and the poor] can be erased from consideration.

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