Freedom to Make Choices for Health: Plus 40 Years

In the 1969 inaugural issue of the School Health Review, Douglass (1) examined four major issues he felt were central to the question of choices one has about health: (1) problems with health care delivery methods; (2) persistent poverty in our population and its impact on health; (3) systemic problems inherent in social and institutional arrangements, what he referred to as the "network of health and health related pathologies;" and (4) difficulty communicating or clarifying values in society, as evidenced by our failure to reconcile the values we preach with the health care that we practice. To begin his thesis, he argued that a person must be understood as a totality rather than as a sum of component parts. To address this perspective, he believed that health professionals must embrace a multidisciplinary approach to health care. W.E.B. Dubois had expressed the same opinion in a study 70 years earlier, addressing a health system which compared the health statistics of blacks with those of whites. Even then, he challenged us to focus on "the absolute condition rather than their relative status." (2(p. 148)) To provide some historical context for the time in which Douglass' paper was written, we gathered statistics on key health indicators such as poverty rate, life expectancy and infant mortality. Poverty rate is a key indicator that defines the very notion of choice and freedom, In 1966, whereas the poverty rate for blacks was 41.8% compared to just 11.3% for whites, in 2008, the poverty rate for blacks was 24.7% and 8.6% for whites. (3) As one could assume, the gaps remain for the other health indicators. In 1960, life expectancy was 70.6 years for whites and just 63.6 years for blacks. (4) Nearly 40 years later, there was still inequity between the two groups. In 2007, life expectancy was 78.3 years for whites and 73.7 years for blacks. (5) Infant mortality rate (IMR) followed a similar pattern. In 1960, IMR was 22.9 for whites and 44.3 for blacks; (6) the IMR in 2005 was 5.76 for whites and 13.63 for blacks. (7) Although many of these overall statistics have improved remarkably over the last few decades, persistent gaps remain between whites and blacks. With all of the progress in the field of health care over the last three decades, why do these staggering statistical differences still exist? These gaps reveal intergroup differences as well as intra-group differences that are not commonly examined. Intra-group differences, as will be seen later, often correspond to systemic problems that remained unaddressed. Are we free to make choices for health? When Douglass asked this question in 1969, he proposed that the inherent structure of the system makes it impossible for individuals to select health. Therefore, understanding the meaning of choice (i.e., right, power, or ability to decide among selections or alternatives) provides a potentially useful perspective in studying the persistent gaps in health inequity from the late 1960s, to today. Furthermore, the question of having choices in health care evokes memories of the 2009 town hall debates (or shouting matches, as it were), in which the question of health care reform became a polarizing discourse. This national debate is at the core of the question regarding choices for health care in the context of the four issues raised by Douglass: a broken down and unsustainable health care system, persistent poverty and the plight of the uninsured, health-related pathologies exemplified in the roles of the tobacco and food industries in today's health problems, and conflicts between American values (e.g., out of many, one; versus looking out for number one). When these four basic factors are combined, the issues of choice and freedom to choose boil down to a question of available options and the comparative benefits that may arise from each. Secondly, there is also the notion that health choices refer specifically to health care. Yet when we explore the context of health conditions, it is clear that health choices made long before clinical encounters create varying levels of vulnerability to ill health. …