Most of what we claim to know, we do not really know. We only think we do. In reality, we rely heavily on assumptions and hearsay.
So when we hear calls for healthcare equity, we naturally assume it to be a good thing. But few fully understand the concept. Equity is not equality, though of late many seem to conflate the two.
Equity means each person, despite different circumstances, receives the clinical resources necessary to reach an equal outcome. Equality means each person is given the same amount of resources, though the outcomes may still vary.
When we call for healthcare equity, we are asking for equal clinical outcomes. But we do not fully understand what it takes to reach this. Clinical outcomes are the result of both resources and patient decisions. We can invest all the care available in tracking a patient’s blood sugar, but it will be all for naught unless she decides to eat responsibly.
No one seriously thinks we should expend resources ad infinitum for a patient who cannot make basic decisions for her own health. Many have even argued that vaccine hesitant patients should not be eligible for organ transplants – on the basis of that one decision alone.
Yet healthcare equity pushes for equal clinical outcomes. This means irresponsible patients should receive additional clinical resources to overcome their bad decisions and the vaccine hesitant should have equal access to life saving surgeries. But this flies in the face of what we perceive to be fair in healthcare.
In reality, we do not want healthcare equity. At least not how we presently understand it. What we want is equity as it is understood in the financial world. In finance, particularly in the world of hedge funds and venture capital, equity is shares of ownership in a company. Different shareholders enjoy different privileges, depending on the number of shares owned and the risk incurred through ownership.
No one questions this because all shareholders know that the privileges given are commensurate to the risks taken. In fact, the sense of fairness comes from this balance. Accordingly, healthcare equity should balance clinical resources with patient decisions. And resources should be given based on decisions taken.
This is what most consider fair, and what most implicitly assume to be true healthcare equity. Not equal clinical outcomes, but outcomes that equally balance available resources against the sum of clinical decisions.
The call should be for patient accountability, not some idealized sense of equity. Hold patients responsible for their clinical decisions while conveying the notion that clinical decisions have consequences.
Unfortunately, this is a hard line to tow. The tendency to devolve toward a particular stance or to moralize certain decisions in favor of others is more than what most can resist.
We are inclined to forgive a hypertensive patient for eating a high salt diet. We are not as inclined for a patient struggling with a substance use disorder. The more polarizing the medical condition, the greater the tendency to moralize it into decisions of good versus bad.
If we truly want healthcare equity, then we should begin by detaching these ethical stances from clinical care. Decisions should be just that – decisions – bereft of ethical biases and seen as purely clinical behavior.
From that perspective, clinical decisions become easier to discern, and balancing clinical resources with patient decisions appears less controversial.
We can then hold patients accountable for their decisions while de-stigmatizing the consequences of them. Allow patients to make clinical decisions as they choose, while choosing not to moralize the clinical resources needed to treat the consequences of that decision.
This is what we mean by healthcare equity – not equal outcomes, but equal freedom in clinical decisions and consequences.
