Considering Values In The Health Care Debate As health care legislation moves through Congress, bioethicist Thomas H. Murray asks if enough attention is being paid to concepts such as justice, fairness and liberty. Murray and health care economist Len Nichols discuss the role of values in the health care debate.
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Considering Values In The Health Care Debate

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Considering Values In The Health Care Debate

Considering Values In The Health Care Debate

Considering Values In The Health Care Debate

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As health care legislation moves through Congress, bioethicist Thomas H. Murray asks if enough attention is being paid to concepts such as justice, fairness and liberty. Murray and health care economist Len Nichols discuss the role of values in the health care debate.


You're listening to SCIENCE FRIDAY from NPR News. I'm Ira Flatow.

And for the rest of the hour, a look at health care and the debate over reform. And if you've been listening to the debate over health care, you're probably starting to feel a little bit of - how should I put it - overwhelmed, fatigued, you've heard enough about it. It seems like talk about health care has been going in one of two directions. It's really black or white in some people's minds.

It's either over-simplistic - pitting evil villains. You have the pharmaceutical companies, insurance companies, big government against innocent victims. And that's how it's trying to be portrayed. Or you might say it's mind-numbingly complex. You got debates about economic models, cost-benefit analysis, all kinds - fiduciary tables. You name it, things that you can't get your - wrap your mind around. And you add to that a thousand pages of congressional bills, you got the jargon of politics, the food fights on cable television. And lost in the fray is the whole reason to have the health care debate in the first place.

So for the rest of the hour, we're going to try to reel it back in by taking a step back and looking at the very basics. We want you to forget about the acronyms, we want you to forget the analysis, the procedural votes. What we're going to talk about are values. What role do values play in shaping our health care policy?

In a series of essays called "Connecting American Values with Health Reform," the Hastings Center, which is a nonprofit bioethics research institute, has tried to address that question, bringing values back into the discussion. And joining me now to talk about it is Thomas H. Murray. He is president of the Hastings Center, and he joins us here in our studio.

Welcome back to SCIENCE FRIDAY, Dr. Murray.

Dr. THOMAS H. MURRAY (President, The Hastings Center): It's good to see you, Ira.

FLATOW: It's good to have you come back and be with us. Also with us is Len Nichols. He's director of the Health Policy Program at the New America Foundation in Washington. And he was senior adviser for health policy at the Office of Management and Budget during the Clinton years of 1993 and '94. And he wrote an essay on stewardship for that Hastings Center collection of essays, which we'll get into in a bit.

I want to thank you for being with us today, Dr. Nichols.

Dr. LEN NICHOLS (Director, Health Policy Program, New America Foundation): Glad to be here, Ira.

FLATOW: Let me start this off with you, Tom. You talk about values in this collection of papers.

Dr. MURRAY: Yes.

FLATOW: And you said that - you mentioned - you talked to all the different players and they seemed to all actually want the same thing, but they couldn't really verbalize it. They wanted something that was just, something with American values in it, wanted something fair, equitable.

Dr. MURRAY: We - that's right. We wanted to expand the conversation both to talk about values that don't usually get mentioned when we think about our health care system, but also to give a kind of deeper exploration of each of the values that we thought were appropriate. And they include everything from justice and fairness, as you've just mentioned, to liberty, responsibility, efficiency and the stewardship such as the one that Len wrote about.

FLATOW: Mm-hmm. You mentioned in there some of these values - freedom, for example. How does that factor, freedom, fit into health care issues here?

Dr. MURRAY: Well, I think most people reflexively would say it's the freedom to choose my own doctor�

FLATOW: Right.

Dr. MURRAY: �or the freedom for a doctor to decide which patients to take. But freedom gets involved in our health care system in another way. Imagine for a moment that you are the parent of the child with diabetes.

FLATOW: Mm-hmm.

Dr. MURRAY: You have a good job right now. You have health insurance. You're under the umbrella of a large corporation, so you've got health insurance. But you also have - you have a dream. You have an idea for a business you want to start, you want to be an entrepreneur. The fact is, if you take that, if you follow that dream, you're almost certainly not going to be able to find affordable insurance that will provide coverage for your child's disease. So, many Americans - we don't know how many millions, but many Americans are caught in this kind of health care job lock.

FLATOW: Mm-hmm. And how did you decide which values to include in your analysis of values?

Dr. MURRAY: Well, we looked at as - sort of many conversations as we could find, and there's no finite and ultimately correct set. But we think all the ones that we were able to identify and find authors willing to write thoughtful pieces about, all of them belonged in the set. And even since we've published it, we've started a blog encouraging people to say more about values in health reform. And we've had people propose other values like honesty�

FLATOW: Mm-hmm.

Dr. MURRAY: �pragmatism and entrepreneurialism, among others. So we wanted to start the conversation around values as a foundation. We didn't think we have the ultimate set.

FLATOW: Because you talk - and in your paper of - called �Values,� that even the people who want to provide health care, they seemed to want to give some -they have a value themselves. They don't want to give it away because they need to make some money on it. On the other hand, they're willing to come up with something that might be equitable for everyone else.

Dr. MURRAY: Sure. And if you're talking about providers in the sense of physicians, they want to be able to - they want to be able to practice good medicine. They want to be able to keep their own integrity as a moral human being intact, and they want to take good care of their patients. So they have values like patient welfare and physician integrity.

FLATOW: You write here - when you talked to everybody, you said, everyone should have to pay their fair share. And when they needed care, their health insurance would be there to cover the cost. We described it as universal participation and, fine, said the insurers. We can agree with that.

Dr. MURRAY: Right. This dates back to the early 1990s when I was chair of a taskforce for the Human Genome Project. We were asked to look at genetic information in health insurance. So we formed a taskforce with average citizens, some experts and some insurance industry representatives. And there was this wonderful - in retrospect, wonderful meeting where the room was basically divided with the insurance people in one corner and everybody else in the other corner. And we said - people in the corner I was in were saying, we want everybody to be insured. And the insurer said, so do we. And they said, oh, universal coverage. And the insurer said, no. And this went on a couple of times.

We finally understood - to them, the universal coverage meant that if you were healthy, you're 35, you suddenly got sick, you could walk into their office, put down a check and they would have to cover you then and there. That, to them, was universal coverage. We said, that's not what we have in mind. We had in mind a system where you had to participate in some reasonable way in the financing of the system all along, but it would always be there to take care of you when you were ill. That's what we called universal participation.

FLATOW: Maybe you're just been using the wrong terms all this time.

Dr. MURRAY: Well, if people like this term, I would be thrilled.

(Soundbite of laughter)

FLATOW: But everybody agreed. Everybody agreed there should be some universal participation.

Dr. MURRAY: The - certainly, the insurance people in that room that day agreed.


Dr. MURRAY: And I know there's some resistance to the idea in the country right now, but I think we should think about the implications of not having universal participation.

FLATOW: Mm-hmm. Len Nichols, let's talk about the essay you wrote about stewardship. Tell us what you mean by that.

Dr. NICHOLS: Well, what I mean is a sort of collective responsibility to pay attention to the way our system, as a whole, serves us all. What I do in that essay is draw on what I think is the best inspiration I could find for how to define a community.

You know, Ira, when we talk about health reform, there are lots of technical questions, but it really boils down to, in my view, who should be allowed to share our health care table-of-plenty. And that is a question of what kind of community, what kind of society do we want. And so, I followed my grandmother's admonition back to �Leviticus,� and I looked at the gleaning rights section in chapter 23 and it talks about how when a landowner harvest their field, they must leave food in the corners of the field for the poor and the alien. And fundamentally, that was about a vision that it was unacceptable to allow preventable starvation to occur.

And what's amazing, of course, is that contribution to our spirituality, and our history, and our social contract - you didn't have to be Jewish, didn't have to be local. In fact, you were expected to be neither. But we had to take care of you. And, in fact, that is an obligation on the community because the stewards are the leaders of the community.

Well, I submit today health care is like food was, a unique gift, capable of sustaining life for people stricken with illness. And all of us can be stricken, so all of us could become the poor and the alien tomorrow. And that's why Tom's right. We really have to think about the implications of not having universal access.

Well, in my view, the requirement in the Scripture is very clear. We've got to make sure the system works for all. We've got to make sure all have the right to participate in the life of the community. At the same time, it does not say in �Leviticus� or anywhere else that everyone gets the same amount of food, that everyone gets the - you know, that everyone gets everything they want. Stewardship has to be exercised. And that stewardship is really about leadership and making sure our system works for all and is sustainable over time.

FLATOW: I find an interesting quote you also wrote, quoting Thomas Jefferson, who was certainly a libertarian type, saying quote, �liberty is to the collective body what health is to every individual body. Without health now, pleasure can be tasted by man, without liberty - without health, no pleasure can be tasted by man. Without liberty, no happiness can be enjoyed by our society.� So he's equating health with liberty.

Mr. MURRAY: Well, that's right. And very few people know that, and I must say, I think it's quite fun to use Thomas Jefferson quote to combat what is some of the current libertarian's argument that the only thing that really matters is food and everything else is choice; and the health care is not different than anything else. We shouldn't worry about people's access to health care. In fact, Thomas Jefferson, in his own words, makes it very clear, without health you don't really have life and liberty. So, yes I do think that's a very profound sentiment.

FLATOW: 1-800-989-8255 is our number. Do you think that we can use a discussion of values to settle a disagreement on policy? Will peoples' minds change? I've never found that peoples' minds change very easily, Tom, or - but perhaps if they look at it as you're saying, that we're all in this together as a country. We have values as a country.

Mr. MURRAY: Yes.

FLATOW: Right?

Mr. MURRAY: Yes.

FLATOW: Life, liberty, pursuit of happiness; or, as Superman said, you know, the American way.

(Soundbite of laughter)

Mr. MURRAY: Well, I've�


Mr. MURRAY: Well, we haven't quoted Superman very regularly�

(Soundbite of laughter)

Mr. MURRAY: �in our papers but will have to look at that.

FLATOW: But it's part of our culture that comes out of what, you know, even though it's a cartoon character, but it comes out of something that is part of our culture.

Mr. MURRAY: Yes. Yes. You can find manifestations of values about health care in many ways in our culture. There's a law known by the euphonious acronym of EMTALA - passed 20 years ago - that essentially requires every hospital emergency room to take all comers in need of urgent care, whether they can pay or not. That's an expression I think of an American value of compassion. We shouldn't allow someone to die or to suffer horribly and needlessly if we have the capacity to take care of them, and irrespective of whether they have money to pay for us - for it right now or not.

If you track that sentiment backwards, I think, it leads you to couple of conclusions. one is that the current system we have of insurance underwriting, for at least - for small group policies, individual and family policies - is morally indefensible. It's a Catch 22. In insurance underwriting, if you come before an insurance company and you've got a very sick family member, let say, with a chronic disease; they least want to insure you the more likely you're to be sick - that is to file the claim. So it works absolutely against what we think health care ought to be about, which is, it should be there when you need it. So there's a Catch 22 built into the heart of our current system of health care.

FLATOW: Len Nichols, give us a little bit of the history of health care - we didn't always have it, did we?

Mr. NICHOLS: Well, no and what's fascinating is to think about, in particular, the history of health insurance. Originally, around the time of the turn of the century and a little bit later, most private insurer - well, all private insurers, eschewed health insurance. They were afraid they could never distinguish between the sick and the healthy. And therefore, they were afraid that only the sick would buy. So, they refused to sell it. The Blue Cross Blue Shield organizations were created out of desperation about the time of The Great Depression, when hospitals figured out regular people�

In fact, the first observation that sort of triggered their inspiration, was when school teachers couldn't afford normal delivery - couldn't afford to pay for a baby being born out of their normal accumulated savings. They realized we had to do something about the cost of health care. So they had the idea of pulling together, across the entire community - again a very communitarian original impulse - have everyone, or at least most people, buy into it and charge them all the same rate; and then they would be covered for their health needs in the hospital.

Initially, physicians opposed that they have thought it was socialism as usual. But then they figured out wait, hospitals are being paid and we're not. So, the doctors formed their own, the hospitals made Blue Cross. The doctors made Blue Shield. They put them together. They were always organized as a non-profit, chartered by the individual states - that's why they were originally 50, and in fact more, few states have more than one. And that's what health insurance was until the commercials figured out, hey, those Blue Cross guys have figured how to make money.

They figured out how to at least break even on this stuff. We can go in there and sell to the healthy and discriminate against the sick, charge the healthy a little bit less than the average priced Blue Cross is charging, and we'll make out like bandits. And that's really when the insurance market became, I would say, beginning down the road of being dysfunctional.

FLATOW: We're talking about health care this hour, on SCIENCE FRIDAY from NPR News. I'm Ira�

Mr. NICHOLS: So, we've been responding to it ever since - it's that spiral�


Mr. NICHOLS: �of selection in competition within a marketplace.

FLATOW: Talking with Thomas Murray and Len Nichols. And so we're now into that spiral. Let's see if we can get a (unintelligible) - quick phone calling before we've to go the break. Let's go to Tom in Denver. Hi, Tom(ph).

TOM (Caller): Hey, how are you?

FLATOW: Hi, there.

TOM: Enjoying the show. And I think it was Mr. Nichols who just addressed the main part of my talk about the insurance companies picking people off, basically. I'm in the investment business and frankly I like insurance companies as a business. So what I was going to comment on, or point out, is that if the object of a profit-making business - which all these companies are - is to pick off the 50 percent of the population that only spends five percent of the health care dollars - and you can make out like a bandit. That's basically why they don't like universal coverage, but the whole idea of insurance is that you form a big pool and then you can sort things out.

FLATOW: Mm-hmm.

TOM: And so what's concerned me in this argument, lately, is that Medicare, which is a right if you're 65 years old in this country and a citizen - they're actually paying the advantage plans of premium of eight to 12 percent over what the Medicare premium that the people pay in.

FLATOW: All right. Let me see if I can get Tom - you were shaking your head a little bit, about this whole thing about making money out of people being sick.

Mr. MURRAY: Well�

FLATOW: Is that a value, I mean, is - where does that fit in with American values?

Mr. MURRAY: Well, I think, doctors have the right to earn a living - nurses, physical therapists, everybody involved in providing professional services deserves to make some money. The people developing effective new drugs and devices deserve to make money. I mean, this is - our effort to stimulate this dialog on values isn't an effort to push a particular idea about what the health care system ought to look like afterwards.

FLATOW: Mm-hmm.

Mr. MURRAY: It's not an effort to bash insurance companies, pharmaceutical companies or anybody. It is an effort to get the American people say, look, what we really care about? In the end, when the dust clears away and we're in done with all the acronyms you mentioned, what kind of system do you want? What foundation should it be built on? And we think if you build it on liberty, justice, responsibility, integrity, quality, efficiency, health, stewardship and some other values - you're going to be happy with what you have in the end.

FLATOW: All right, we have to take a break. We'll come back and talk lots more with Tom Murray of the Hastings Center. Len Nichols, Director of health policy program at the new American Foundation. Our number, 1-800-989-8255. Stay with us. We'll be right back.

(Soundbite of music)

FLATOW: I'm Ira Flatow. This is SCIENCE FRIDAY, from NPR News.

(Soundbite of laughter)

FLATOW: You're listening to SCIENCE FRIDAY, from NPR News. I'm Ira Flatow. We're talking this hour about the values and the health care legislation that's being considered. My guests are Thomas H. Murray. He's president of the Hastings Center in Garrison, New York. Len Nichols, director of the health policy program at the New America Foundation in Washington. Our number, 1-800-989-8255.

And this just came over the wires a few minutes ago that - I'll read the AP story to you. House Democrats acknowledged that they don't yet have the votes to pass a sweeping overhaul of the nation's health care system and signaled they may push back the vote until Sunday or early next week. I know Len, you've been following this for almost two decades, right?


FLATOW: What's your comment about that, if you might have one?

Mr. NICHOLS: Well, I just think that these things are complicated. They're - they're are many, many, many moving parts and at - when you get close to end game - and we are getting closer to end game in the House - people tend to focus on the one or two things that matter the most to them. And since it takes 218 yeses to pass a bill, that can require quite a number of, more or less, bilateral conversations. So, I think that's what this means. I always thought it was a little optimistic to think they could reach a closure that quickly.

What I think it does do, though, is signify when at the end of the day, when they get down to finally voting, once the whole package is on the table, then it does come back to what Tom's initiative has done. What are their values? What do we want to do? What signal are we sending to our people and to - specifically, to their constituents, but obviously generally to the American people as a whole. What kind of health care system do we want? What kind of government do we think we actually have? That's what they end up voting on every single time.

FLATOW: You know, I was - before, we went in on the air, I was trying to pencil in some of the values that we see everyday that Americans say that they want. And I, being the end of the World Series, I saw lot of baseball - being a baseball fanatic.

(Soundbite of laughter)

FLATOW: And I also, being in the middle, now, of Thanksgiving, the big football season is in headway, we're going to have everybody coming home for Thanksgiving and homecoming, I thought about some of the sports terms are very much are the values we hold dear. And I wrote them - some of them down. Leveling of the playing field, we use that a lot. That's right.

Mr. NICHOLS: Yeah.

FLATOW: We have umpires, we have instant replay, we have, you know, we want fairness in our sports. These seem to me to be the same values, you could say to health care people. Do you want all these values in this health care talk that we're talking about - whether you're an insurance person or someone who's going to be insured, or it's a health care provider. I mean, those are the things Americans talk about. They, you know, they want the instant replay in baseball because they wanted to be fair.


FLATOW: The value of being fair to everyone. I think you pointed that out, that when you sit in the room together and you ask everybody, they can actually agree.

Mr. MURRAY: I'm trying to imagine.

FLATOW: You know�

Mr. MURRAY: �the use of instant replay in the operating room. This is�

(Soundbite of laughter)

Mr. MURRAY: �probably not going to be welcome by all of our surgeons.

FLATOW: Right. But to everybody, I think, you're right. And Len, wouldn't you agree, if you got this bill, like Tom did when he got everybody into a room and he sat down and he said, you know, we're actually in more agreement about some of these things then we thought we were?

Mr. NICHOLS: Well and that's exactly what I would say is a difference in '94 -I mean, today compared to '94. In '94, I don't think enough people got in a same room. And I think now there's been much more of that. And to me the main reason is because health care has come to cost so much, we've seen that more and more people are being excluded from our system and more and more professionals within it understand our system is actually not sustainable so we don't really have a choice of maintaining the status quo.

And that's why I think you see more and more people willing to come together, long enough to understand as Tom said they actually do have a common framework. They often, however, enter the conversation with very different rhetoric and words. And that's what takes time to sort through. But, yeah, the core American values - and I agree with you, Ira, they are basically all in baseball. The core American values are shared by far more people than sometimes the mainstream media, evening news, would let you know.

FLATOW: Tom, you agree with that?

Dr. MURRAY: Completely. You mentioned fairness. There's a concept that the insurance industry has used called actuarial fairness. Actuaries are the people who create these tables and they figure out your likelihood of filing a claim and that's how you get insured against. It makes perfect sense if I'm trying to ensure my shipping fleet and I'm taking safe routes and my competitor is going right through the Somali pirates' waters.

FLATOW: Right.

Dr. MURRAY: I know I shouldn't pay as much as he does.

FLATOW: Mm-hmm.

Dr. MURRAY: But when it comes to health care, the need for health care, all of us should - fairness there consists of having access to the care that we actually need when we need it. So it's a different idea.

FLATOW: But that brings in Len's idea of stewardship. That's another American value that we all - we help each other out in times of crises.

Dr. MURRAY: Yes.

FLATOW: We are - you know, even people not talking about being stewards of the Earth, when we - people are talking about - and we know the environmental movement is gaining people it didn't talk about before because they now consider themselves stewards of the Earth.

Mr. NICHOLS: You know, and you mentioned Superman earlier, I would even suggest go back and look at those John Wayne movies. They're free now. And go back and look at them late at night. And what you will see is, in addition to the lone cowboy ranger being the star, there was always a posse who was helping him. There was always a schoolmarm to make them take off their hats. There was always a preacher to bury the dead and marry the recently reformed saloon girl.

Fundamentally, there was always a community. And the purpose of community was to make it possible for the lone ranger to do his thing, make it possible for each individual to succeed to the limits of their ability. That community value is part of individualism. It's a necessary part. And we have lost the connection in our over-emphasis and, frankly, in some of our partisan politics.

And that's really why I was so happy to participate in Tom's project here because it seems to me bringing these values together and making them clear, then, in fact, more and more people see they share them. And then you've got a chance to work out a solution.

FLATOW: David(ph) in Minneapolis. Hi. Welcome to SCIENCE FRIDAY.

DAVID (Caller): Hi. Thanks for taking my call. Just one, kind of, thought I had: A couple hundred years ago, we really - the society came together and said the institution of slavery was wrong. It was wrong to have this subclass of people. And just - I think some parallels can be drawn between that and today's society where we really said with slavery: freedom is a fundamental right, it's a fundamental thing that everyone needs - seems like we're saying a lot of those similar things about health care. It's a fundamental necessity. It's a fundamental right. And so, if we're valuing these same things, how can we not say, hey, everyone, we need to have universal coverage. Thank you very much. I'll take your response off the air. (Unintelligible).

FLATOW: Okay. Thank you. Any reaction? Tom?

Dr. MURRAY: Well, in Len's wonderful essay, and I'm particularly proud of his essay in stewardship in this collection, he cites the Institute of Medicine's study that about 20,000 Americans die each year just because they don't have health insurance and then don't get the health care they need now. That means, since the last debate on health reform under the Clinton administration, about 300,000 Americans have died simply because we don't have a health insurance plan that works for everyone. That's unconscionable, I think.

FLATOW: Mm-hmm. Let's talk a little bit about, Tom, the value of responsibility. You put that as one of your values. When you're talking about the responsibility, you can also veer off into a discussion about how people are responsible for maintaining their health.

Dr. MURRAY: Yes.

FLATOW: Like smoking - things like that.

Dr. MURRAY: Yes. I mean, people have to take responsibility for doing what's necessary to take care of their own health, just as they have to take responsibility and universal participation for - participating in some way in the financing of this system. So responsibility has many aspects in health care. But that's a core American value and it belongs to the conversation as well.

FLATOW: Mm-hmm. 1-800-989-8255.

Len, is employer-based health care part of our value system?

Mr. NICHOLS: Well, you know, that's a great question. And I would say, in a way, it is an accident of history. As you probably know, we didn't have employer-based coverage until World War II. And during World War II, of course, in an attempt to try to suppress inflation, which is often a risk in wartime economies, we had wages frozen by the government. And when they froze wages at the same time with so many men and even women but certainly a lot of people fighting overseas, we had a shortage of labor, so firms were competing for workers. And they wanted to offer them something. They couldn't raise wages so they offered them health benefits, and that's really where employer-based coverage came from. Then the Congress decided to make it tax-free to do that as another inducement to give employers a tool for recruiting and that tax-free dimension of the employer-provided benefits solidified - became the glue that then became the cornerstone of the way we get coverage.

In a way, it fits the American vision of private provision as much as possible. And for, you know, most of the post-war period, from 1940 until about 1970, it seemed to work reasonably well. Seventy, 75 percent of our population was covered that way.

But as health care became more expensive, as markets became more global and more firms were competing internationally with countries that have more efficient health care systems and rely less on employer financing, our ability to compete internationally, as you've seen lately, has gone down. Employers offer way less than they used to, and now we're below 60 percent of our population covered in an employer framework.

And I'd say reform that we're talking about now in Congress will not end the employer system but it will replace it for small firms, which have the most health trouble in the insurance market, and give individuals who've never had a group offer a place to buy health insurance efficiently and fairly. And I would predict over time the large firms will move their workers in there, too, but it may very well take 20 years or more.

FLATOW: Mm-hmm. If Thomas Jefferson wrote life, liberty and the pursuit of happiness, and in his writings equates happiness with the ability to be healthy - because you can't really be happy unless you're healthy, as we pointed out before - that would seem to be something that the founding fathers thought that should be universally, you know, guaranteed to people, as much as housing and food and education and things. That should be something that should be offered to people as part of their way of life.

Dr. MURRAY: Well, in Jefferson's time, most health care probably didn't do you much good. Doctors�

Mr. NICHOLS: In fact, it was harmful.

(Soundbite of laughter)

Dr. MURRAY: Doctors were - if they were good, they kept you company. But they did - there wasn't much they could do to alter the course of a disease. Today, obviously, it's completely different.

FLATOW: Mm-hmm. Len, do you think that - when we talk about fairness, do you think that that would be part for a stewardship that - no one being left out of health care would be part of stewardship?

Mr. NICHOLS: Well, that's certainly the way I view it today. I think it's the way a majority of people view it today. I think if you go back to Tom's very good point, in the 18th century, I don't know that Thomas Jefferson would have thought health care was effective enough to make it desirable to be universally accessible. But I do think that if Thomas Jefferson read the Institute of Medicine report that Tom cited and I cited in my work, he would definitely agree. If nothing else, Thomas Jefferson was an evidence-based human being.

(Soundbite of laughter)

Mr. NICHOLS: And he would definitely go with, look, if this is costing us this much economic output and it's costing us this much moral anguish, there's no question it's at least as important as education to being a full citizen. And I think he'd be there. And that's why I think he differs quite clearly from what some of his would-be adherents claim on his behalf today.

FLATOW: Talking about the ethics of health care this hour on SCIENCE FRIDAY from NPR News with Tom Murray who is a bioethicist and president of the Hastings Center, Len Nichols, director of the Health Policy Program at the New America Foundation.

Just a few minutes left, gentlemen. Any final thoughts of where this might be headed and what you would like to see?

Dr. MURRAY: Well, there are a couple of ideas we haven't talked much about, today at least, although they're in the collection.

FLATOW: All right. If you could...

Dr. MURRAY: Sure. And they're going to be equally important in creating a sustainable system for us. Quality is an elemental value in health reform. Not enough of our efforts are focused on ensuring quality and studying how to deliver high-quality care.

FLATOW: Mm-hmm.

Dr. MURRAY: Another value is efficiency. I mean money wasted on health care is money wasted. And we spend, as all the pundits tell you, we spend far more for per person on health care than anybody else in the world and we don't get results that are superior. In fact, in many ways, they're inferior. So we have to work more on quality. We have to work more on efficiency. That will help make for a sustainable health care system in the future.

FLATOW: Mm-hmm. Any other final thoughts, Len?

Mr. NICHOLS: Well, I would just go back to what, I think, you said earlier when you asked about the vote. I mean, I think at the end of day, this is going to come down to the president of the United States explaining to the American people why he thinks this reform is consistent with the values they hold most dear. And I believe the opposition to it will try to persuade them of the same thing.

What is sometimes true is that those values seem to differ among political antagonists. But I think what Tom has taught us, and certainly what I believe, is that when you probe deeply, and when you get them in the same room in a dialogue, you can find out their values are actually shared. And I believe most people share them, and therefore I do believe we will end up with a bill that moves our country forward. It won't be perfect. It won't be perfect. But we will continue to try to get our values reflected in that system tomorrow and 10 years from now and 100 years from now.

FLATOW: Do you think voters care about the values, though? Do you think they think about values or are they thinking about their pocketbooks?

Dr. MURRAY: Well, both. I mean, you'd be foolish not to think about your pocketbook.


Dr. MURRAY: Health care is a big expense for many people and for the country. But I think talking about values gives people a purchase as sort of a way into the debate that otherwise they're excluded from. Otherwise, it's people shouting talking points at one another or health policy experts using the acronyms that nobody else understands.

If you - all of us can talk about values. We can talk about it in a sophisticated way. And if we want to maintain a civil dialogue, it's a wonderful�


Dr. MURRAY: �instrument within which to (unintelligible).

FLATOW: Yeah, because everybody can bond around these values�

Dr. MURRAY: Yes.

FLATOW: �and then maybe see the view of the other person a little easier.

Dr. MURRAY: Yes.

FLATOW: Because they - like you say, they're not at each other's throat about the other issues.

Dr. MURRAY: And we've - to follow up on our essay collection, which is available free on the Hastings Center's Web site, there's also a values in health reform blog that we're co-sponsoring with the journal Health Affairs. And people can go to that blog. They can read the postings and they can and their own responses. We welcome that.

FLATOW: Where is that blog?

Dr. MURRAY: Go to - and you can follow the links to that blog.

FLATOW: Mm-hmm. And Len, you're - are you part of this blog, too?

Mr. NICHOLS: I am. And we also have a blog on our Web site - New America dialogue blog. And, you know, same thing. Go to New America, go to the health policy Web page and follow the links. There's a tremendous amount of discourse going on around the country. And I think your listeners would definitely enjoy it and then participate. We welcome that, absolutely.

FLATOW: And if you forget all that stuff, you just go to We have the links up there.

Dr. MURRAY: Great.

FLATOW: So just one number or address to remember. Thank you, gentlemen, for taking time to be with us today. Len Nichols, director of the Health Policy Program at the New America Foundation in Washington, Thomas H. Murray, a bioethicist and president of the Hastings Center.

Dr. MURRAY: It's been a privilege, Ira.

Mr. NICHOLS: Thank you, Ira.

FLATOW: You're welcome.

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