The ethics of swimming pools.

My job was simple: Write an essay reviewing four exciting books--two on the general topic of health care justice, and two on health care policy. 1,103 pages of scholarly discourse, and what did I find myself thinking about? Swimming pools, of course. I take care of patients within the Veterans' Administration system. Most of them have limited financial means and suffer from multiple chronic illnesses. Virtually all would be better off if they exercised regularly. I urge many of my patients to take walks, but a large number of them cannot follow this advice. Some live in unsafe neighborhoods. Some have physical problems that limit their ability to walk. Swimming pools are one of their best exercise options. But do you know how much it costs to use a swimming pool? In Ann Arbor, where I live, a single trip to a public swimming pool costs four dollars. Visiting three times a week will set a patient back $624 per year. Many tell me that such an expense is simply beyond their means. We live in a country, it seems, where we are happy to pay for veterans' diabetes pills, hypertension medications, and cholesterol pills, but not for three visits a week to a pool where they might begin to get in good enough shape to get off some of their expensive medicines. Health problems like diabetes, hypertension, heart failure, and hyperlipidemia (high cholesterol) are often the result of complex social forces. That means that the job of physicians like me is bigger than it used to be. It doesn't end when we've checked a few blood tests and prescribed the relevant pills. Many of our patients are sick because they eat too much or exercise too little. They suffer from stress due to bad neighborhoods or financial problems, and the stress wreaks havoc on their cardiovascular and immune systems. A blood pressure pill and a couple of Xanax simply won't do the trick. If we want to help our patients, we need to address the fundamental forces influencing their health--hence my obsession with things like affordable swimming pools. I am not naive enough to think that a swimming regimen will solve my patients' health problems, but I do believe that it would be a nice start: helping people burn calories and blow off steam, encouraging positive social interactions, and maybe even building muscle strength to protect their fragile joints. While I was reading these four books, I was pleased to discover that I was not alone in my obsession. While meeting with a physician who had just moved to Ann Arbor from Philadelphia, where she had worked in a community health center, I found that she, too, encouraged her patients to swim and encountered the same barriers I did. Being a better person than I, though, she didn't give up, but instead took it upon herself to compile a list of neighborhood swimming pools, along with their pricing rate at various times of the week, to distribute to her patients. Before she left Philadelphia, she had been planning to visit these local pools to negotiate more affordable rates for her patients. A physician who believes that her job description includes negotiating swimming pool fees? Clearly, as more physicians recognize the broad societal forces influencing people's health, their view of their proper role will broaden. I expect that many bioethicists--especially those who study issues of justice and resource allocation--are also recognizing that their job description goes well beyond what it used to. When I was first introduced to the field of bioethics back in the early 1980s, I took special joy from the section of the course dealing with health care justice. We wrestled with "lifeboat ethics," deciding (hypothetically) who should live and die if there were not enough dialysis machines or intensive care unit beds to go around. Once we'd solved these microallocation dilemmas, we moved on to the big picture stuff--the macroallocation issues such as, is there a right to a decent minimum of health care, and, if so, what does that right entail? …