Scale Down: When Bigger Isn’t Better

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Aristotle and the ethics of localized healthcare governance

We begin another calendar year, another chance at renewal and redemption, another shot at ridiculous resolutions to lose weight, cut out sweets and get more exercise. I personally have resolved to call more old friends and waste their time on the phone talking about absolutely nothing. I have come to the realization that in a 13.7 billion-year universe, in which man may be just a passing fancy, these relationships are unimaginably important.

We are so caught up in the regrets and problems of the moment that we repress what has been the beauty of our lives. While this government still allows individual citizens to pursue final ends as they understand them, lets rejoice. In truth, the private space that this government bequeaths to eudaimonism is probably too small to hold the truly good lives we wish to live. Political flourishing is an essential aspect of human flourishing. The two cannot be taken as separate ideas in either theory or practice.


To this end, my resolution this year, besides reestablishing relationships, will be to better understand these true happiness projects, one of which will be to reread Aristotle’s Nicomachean Ethics and the more recent philosophic works of Deneen, MacIntyre and Hannon. Add to this list the proceedings of the Fourth Lateran Council of 1215 and I have a pile of reading materials that would cure insomnia better than Harrison’s Textbook of Medicine.

What, you might say, has this to do with medicine in America in 2014? I have been told by more than a few people that they’d appreciate it if I published this column in some obscure philosophic journal and stopped wasting their time. I counter with the fact that all applications of science to medicine and all applications of medical knowledge to the individual are value-based and philosophically driven. I contend that the decisive issue of our time will not be same-sex marriage or genetics or even surveillance by the State. Rather it will be fought over the fundamental basis of a free people, i.e. expression and suppression of those rights supposedly guaranteed to us in the Constitution. Freedom of all speech, not just politically correct speech. Religious liberty and freedom of assembly and association. These are the ideas and values that the Founders gave us and which we run the risk of losing.

My decision to reconnect with the Nicomachean Ethics is not without conflict in my own household. My wife just writes me off as a hopeless nerd. My dog, on the other hand, is a problem. I am Aristotelian through and through. The dog, Tucker, is a pure Platonist – a Republic-spouting, Marxist-Socialist bastard. He looks up to me as I am perusing the Ethics and says: “So you’re reading him again?” “Yes,” I reply. “But I’m not letting you comment, since he is much too sophisticated for a communist dog like you.” He quickly replies, “Puppies of the world unite! We have nothing to lose but our leashes!” Biting the hand that feeds him wouldn’t be Tucker’s style, but he’s perfectly happy exercising his freedom of speech to insult my intelligence.


I had barely gotten into Aristotle when I realized the real relevance of his genius to the healthcare discussion surrounding us. The term of importance here is “scale.” The government supplies services to consumers; no more, no less. If they can’t do that, they do nothing and citizens have a right to seek services elsewhere. While “bigger is better” (God, I hate this term) may be useful for certain enterprises such as uniform money and national defense, the present size of America makes supplying services and “happiness” (as Aristotle understood it) almost impossible. Aristotle believed – and several times states – that the polis population cap should be somewhere around 100,000. The United States sits at about 314 million, and that’s only those we can count.

We are too big to give out personal services like healthcare as one lump. We all know from experience that bigger isn’t always better, so why don’t we apply this logic to the federal government? James Chastek once commented: “At some point the size of a government hits a tipping point where it no longer is the actions of us but of it; and we can no longer look to it as an institution within which we can exercise political life but only a leviathan that we must appease with taxation offerings and paperwork and exploit for whatever resources it might offer us.”

Think again of the great things in your life. Does anyone want Amherst to turn out 20,000 students a year instead of about 500? No. Big is not better when size means that an institution cannot understand the services it is giving to the individual. To quote MacIntyre: “It is only insofar as those features of the Polis which provide an essential context for our lives that the Aristotelian schema of practical reasoning can be re-embodied in one’s own life…”

In other words, all services must be a collaboration between the person offering and the person receiving that service. Government gets too big to understand the variations in its people and the individual can’t “right” the ship of state.


Thankfully, we have the perfect political subdivisions in place to carry out the mission of healthcare: the States. This is where we can figure out why Minneapolis spends one-third the amount of Medicare money as does Miami or New York City. If the people of Florida want expensive, inefficient medical healthcare, let them tax themselves for it. Let’s decide in smaller units what really is “good healthcare” (a term more often used than understood). By the way, have you heard any politician define “quality healthcare”?

We need to have a forum where real debate can go on regarding multiple broad areas of healthcare such as duplication of services, physician variation and lower outcome despite increasing costs. It is perfectly reasonable that we can use multiple centers around the country to perform certain unusual and expensive procedures. There is no reason why every State must maintain every capability. Furthermore, we need to decide what the Polis will provide and what the individual will do for himself or herself. MacIntyre warns us that we have become a culture which does not understand shared ideas of sacrifice but does what it can to get whatever it can from the impersonal “big government.”

Think about it. There isn’t a public employee who doesn’t know the exact number of days they have before they can wander into a lush retirement. The largest decision going on now in the bankruptcy of the City of Detroit is: Who’s going to pay for pension plans, healthcare, and other things that were promised and not funded? If you believe that the federal government will do it better than the City of Detroit, good luck. It never has in the past. It’s nobody’s money in most people’s minds. It’s the government’s money.

Here’s the catch. This parade of stealing-all-you-can-from-the-nameless-and-faceless-government isn’t some abstract problem where we get to stamp and huff and blame our enemies. The problem starts with us. We reflexly blame the lawyers and malpractice for all the stupid over-testing and the torturing of old people at the end of their life. But we are just as much to blame. We let the young physicians lose examination skills so they only believe in testing and numbers. We allowed them to lose all insight into meaning. “Why are we doing these things?” is the question that should be asked. Why are there more people getting rich off of diseases in America than dying from them? We should not be pleased that this year we dropped from 17th to 24th in male longevity, female longevity and infant mortality worldwide. Are you really proud of the fact that we are first – and by almost double the number – in the amount spent on healthcare? There is a fundamental disconnect between what we do and what we get. We wouldn’t put up with it in any other industry. Why are we willing to put up with it in medicine?

Whenever there is a huge national program, all the piggies come to the trough to see what they can get. It’s not what is in the best interests of the actual healthcare for the citizens of America, but what’s best for lining the pockets of healthcare providers.

“So on we work from sun up to sundown and went without the meat and cursed the bread,” so to speak. The current healthcare debate is focusing on all the wrong issues. The website fiasco, as bad as it is, is a far cry from the real issues. Do you think a government which thought that the Arab Spring was a great idea, shunned Israel, took no responsibility for Benghazi and has doubled the national debt with no substantial change in unemployment is going to ask the correct questions in healthcare?

Until we ask what people really need and can afford, we will get nowhere. And the federal government does not lend itself to serious debate on dealing with local and regional issues. We can have more reasonable healthcare for half the current money if we understand we need to do it in conjunction with average Americans who can understand the product. Canadians do it through each Province. The British do it through health regions. Virtually every Western democracy larger than the Dallas Fort-Worth Airport uses some kind of regional system to compensate doctors and deal with regional healthcare needs. What about us? When are we going to come up with something we understand, can influence and control?

It’s time to conclude. My dog is again quoting from Alfred North Whitehead on how “all philosophy is merely footnotes to Plato.” In his quick read of this column, he concludes that all my phone calls will not only be catalogued and listened to and probably filed in some federal bank for future prosecution against me, but chances of a continuous series of tax audits has gone up logarithmically. So what’s new?

Quod avertat Deus


Dr. Henry is the founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP.

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