The Health Care System as a Dysfunctional Family

Feature Article

The Health Care System as a Dysfunctional Family

John C. Sonne, MD

This article describes how the ever increasing control by third party payers of the physician-patient dyad is reinforcing family dysfunction and producing a regressive deterioration of the health care system into a system resembling that of a dysfunctional family. A component contained in both systems is a lack of respect for autonomy and individual freedom through the exercise of tyrannical control in the name of compassion and care.

The Erosion of Liberty by the Misuse of Words

James Madison made the point over a century and a half ago that the real threat to the erosion of liberty comes not from major and conspicuous changes, but from small steps that are scarcely discernible. This caveat applies to the health care reform movement. The small steps by which liberty is being eroded in the dysfunctional shift in the health care system are the at-first-glance seemingly innocuous misuse of words. Both Orwell, in 1984, and Hayek have commented on such a process. Orwell used the term "double speak." Hayek warned in his chapter, "The End of Truth," of the dangers of the perversion of language by social planners, the creation of myths often emanating from a single source, and "the destructive effect on all morals by the undermining of one of the foundations of morals: the sense of and the respect for truth."(1) [Emphasis added.] He pointed out that "the most effective way of making people accept the validity of the values they are to serve is to persuade them that they are really the same as those they have always held, but which were not properly understood or recognized before. And the most efficient technique to this end is to use the old words but change their meaning."(2)

This misuse of words in naming entities and processes is a trait held alike by health care reformers and the parents in dysfunctional families. Both use this to distort, mystify, and impede individual and social development. Examples in the health care debate of not calling things what they are can be seen in such terms as health care reform, health care crisis, right to care, third party payer, purchaser, provider, certification, preferred, relative value, managed care, managed competition, high cost of care, cost effective, quality of care, quality assurance, medical necessity, access to care, mental illness, counseling, authority, responsibility, and the oft repeated statement that there are 37 million chronically uninsured citizens in America today.

The use of these words redefines the facts, the terms of debate, the processes, the problems, and the roles in the physician-patient-insurer triad. It seductively diverts attention away from the fact that third parties are inappropriately intruding into the relationship between the patient and physician, eroding the autonomy and freedom of each. Expressions of concern conceal the insurer's underlying profit motive. This process did not begin with the Clinton administration. Private insurers, emboldened by much of the language and policy of the Medicare-Medicaid legislation of 1965, have been redefining words for decades.

In addition to the misuse of words by third parties, an outright denial of facts, even to the point of denying their own words, accompanied by scoffing at dissent, is a trait held in common by many health care reform promoters and dysfunctional families.(3,4)

Paul Starr describes how the assault on what he terms the "sovereign profession" of medicine began: "The attack on medical care originated with increasing criticism in the 1960s of psychiatry and mental hospitals....Psychoanalysis, sad to say, had trouble passing the test of cost benefit analysis....Politically irrelevant in the sixties, cost-ineffective in the seventies, psychiatrists took it on the chin from all sides. From psychiatry, criticism spread to medicine at large."(5,6)

Examples of the Misuse of Words

The opening wedge used by those who wish to totally replace and control the health care system is to repeatedly proclaim that there is a "crisis" in health care in America.(7) Even though the term "crisis" is a misrepresentation, the term "health care reform," builds upon it to suggest what is needed as a solution to the "crisis" is a complete takeover of the traditional medical system.

There is an additional distortion in the use of the term "health care" as a replacement term for what has generally been thought of as medical care. The treatment and prevention of disease now becomes health care, with the implication that we are no longer talking about disease and physicians, but about the dependent illusion that someone other than oneself is to be responsible for the care of one's health, generally considered to be a personal responsibility.

The addition of the word "reform" suggests that if we reform or control everyone's overall health care habits, disease and the infirmities of old age will be eliminated. Beyond this, the term disguises the fact that what is really being talked about is physician reform and the regressive revision of the traditional physician-patient-insurer triad into a system isomorphic with that of dysfunctional families.

The First Step: Viewing the Patient as a Helpless, Dependent Child

Although the misuse of language is a major component in facilitating the promotion of major health care reform, the most crucial first step underlying efforts to distort the traditional physician-patient-insurer triad is one that is executed non-verbally and is almost indiscernible. This step is the unsaid usurping shift of viewing the patient as a dependent, helpless child, and the physician and the insurer as parents. It is the most fundamental distortion of all. It is not named, but is implicit in its acting out.

Isomorphism

One of my aims in discussing this issue of social psychopathology inherent in current and proposed health care reform is to expose this shift, and show how the structure of the health care triad is shifting from one of adults to one that is isomorphic with the structure of a dysfunctional family, a structure that is replete with socially reinforced disorders of self and desire. In this shift, the patient, treated as a helpless, infantilized, dependent child, becomes entrapped, like a child in a dysfunctional family, in two pathological dyadic relationships, one with his physician parent and one with his insurer parent.

The physician and the insurer become engaged in a conflict which resembles the splits in the marital-parental coalition common in dysfunctional families, similarly characterized by lack of mutual trust and respect. They argue with each other about who is the more powerful parent in control of their relationship, and argue about how to care for their children, i.e. patients. In this regressed and socially shared pathological system, the insurer plays the part of a providing and controlling mother, who exercises control over the weakened father-physician and the dependent child-patient, and drives a wedge into the physician-patient bond. As with children in matriarchal families, patients look more and more to the insurer-parent as the controlling third party for gratification, cease to negotiate with the physician-parent, and on top of this expect the weakened physician to deal in their stead with the insurer.

Transferences of Pathological Family Images

In essence this process involves a reciprocally reinforced transferential acting out of pathological family images in the health care system.(8) The term acting out used here refers to a defensive process whereby psychological conflicts, often arising from difficult childhood developmental experiences with one's parents, are transferred to others and acted out behaviorally. Applying the concept of transferential acting out can be helpful in understanding the dynamics of the socially shared psychopathology of large social movements.(9)

Forgotten in this acting out of pathological family images is the fact the patient as a mature and independent person initially contracted of his free will with the physician for care and with the insurer for reimbursement. Also forgotten is the fact the physician and the insurer in the traditional system had no direct contractual relationship.

Physicians who have recently contracted directly with third party insurers are unwitting colluders in this process as well as victims. The patient, as with a child in a dysfunctional family, is likewise not only a victim in this process, but is a colluder in fostering it through surrendering his individuality, and through his regressive expectation of unlimited entitlement to gratification of his unrealizable desires.

Further Examples of the Misuse of Words

Further distortions of language that take away the freedom of both physician and patient are the use of words such as "third party," which place the insurer on an equal or higher footing than the physician and patient. The word "preferred" is used to define the insurer's preference, not the patient's or his physician's. The word "certified" is co-opted by the insurer from professional certifying and licensing bodies. The word "payer" suggests that the insurer, not the patient, pays for treatment, rather than that the insurer reimburses the patient.

The term "benefits" suggests that employees are being given something by their employers, rather than that their insurance, often more restrictive than a policy they might purchase elsewhere, and non-portable at that, is in actuality in lieu of a higher salary. The word "purchaser" suggests, and in fact is becoming true, that the insurer or the employer, not the patient, has contracted for and is receiving treatment. (Is the insurer then the patient?) The use of the term purchaser also suggests a commodity and a business transaction.

Using the word "provider," rather than physician by insurers implicitly diminishes the role of the physician and suggests that the insurer is the provider. (Is the provider then the physician?) Its use in describing HMO plans, as in "this plan provides etc." suggests this to the public, and in practice this tends to be the case, even though reviewers protest to physicians that they are merely authorizing what treatment they will pay for, and that treatment decisions are the physician's alone. This is tergiversation at its worst, and the result of this obfuscation is that the physician, under the threat to his patient and himself of what amounts to an economic boycott, finds himself in a position of responsibility without authority. His responsibility includes a concern that his patients receive proper care, and his being liable for malpractice. Insurers claim this concern for patients when they speak of "quality of care," but so far they have been protected from suit on the grounds they technically are not practicing medicine, even though they claim for themselves the definition of what is "medically necessary."

It seems to have escaped most people's notice until recently that the words in the Resource Based Relative Value Scale (RBRVS), which places a dollar value on arbitrary subdivisions of a person's entire mind and body, opens the way for insurers to exercise financial power over the thinking, feeling, and behavior of the citizenry and even the ultimate power of deciding who shall live and who shall die. Diagnosis and treatment must be "cost effective."

A similar control over what is important in a person's life is to be seen in the word "function" in the "global axis of functioning (GAF)," which, in rating on a percentage scale a person's ability to work or function, places utility above whatever degree of objective or subjective handicap a person may have that severely limits his life and health. (If you can work, and you are on your feet, you don't need help. You are part of America's healthy work force.)

The "Non-Participating" Physician in Medicare

A further distortion, this time mis-characterizing the freedom of the physician, and indirectly that of the patient as well, can be found in the definition of what is termed the "non-participating physician" in Medicare and Medicaid. The term non-participating suggests that such a physician is out of the Medicare-Medicaid system, whereas he is in fact part of it, and is bound by its regulations as much as is the participating physician. Even the truly non-participating physician is in effect indirectly forced to be a part of the Medicare-Medicaid system by exclusion, since he cannot continue to be consulted by his gradually aging patients if he does not join the system.

Divisions in the Medical Community

A further use of innocuous terms which deflect attention away from focusing on and limiting controlling third party intrusion can be seen in the increasing use and acceptance of terms like "managed care, "quality assurance," "cost-effective," "health maintenance organization," "managed competition," and "peer review organization." The surrender to third party control can also be seen in the formation and naming of subspecialty groups which are fracturing medicine and proliferating at such a rapid pace that it is difficult not to conclude that this is as much in response to the need to obtain reimbursement from third party insurers as it is to improve patient care.

Excessive subspecialty certification promotes the proliferation of practitioners who are narrowly focused, rather than physicians who have comprehensive knowledge of, and are able to treat the whole person. The rush to respond to what amounts to the threat of an economic boycott of physicians by third party insurers and the government has created serious divisions in the medical community. In what many physicians consider to be a stampede-like surrender or sell out by their colleagues, many physicians, and hospitals as well, have yielded to accepting, or even endorsing the control of medicine by third parties, communicating by their actions and statements that they consider the major health care reform proposals being promoted and instituted as inevitable, or constructive, and that there is no use in fighting them or trying to hold on to what other physicians see as good in what we have. Even professional courtesy is being rendered meaningless.

Equality

The word "equality," pervades discussions in health care reform. Yet, the concept of equal rights as expressed by our Founding Fathers can be misinterpreted as meaning equalization or sameness.(10)

In family therapy the expression of such a misinterpretation --- presented in terms that each child in the family is to be treated the same --- is considered to be a pathognomonic diagnostic indicator that a family is dysfunctional. The idea that all the children in the family will be treated the same is a "one size fits all" policy that takes away the uniqueness, interests, talents, needs, and contributions of each individual child. Everyone must be happy, and everyone must be healthy, even though they are not. In fact, the opposite usually ensues. Dysfunctional families are replete with examples of more unhappiness, more competition, and more sickness.

In many dysfunctional families children are psychologically or physically abused, or aborted, the elderly are neglected or their deaths hastened, and family relationships are strained or disrupted, all of this rationalized as being done in the name of love and care. Such was the case in the totalitarian state of Nazi Germany's implementation of a benevolently proposed need to improve the general welfare and reduce the cost of medical care. This required thought control by the leader, a mandatory love of him, and cooperation by the medical community. It resulted in the elimination of the lebensunwertes through abortion, the mentally handicapped and the frail through euthanasia, and eventually the destruction of the Jews. Some of the misguided health care reform plans being promoted today in America seem to be headed down the same path.(11)

A further misuse of the word equality is seen in the manner in which someone in authority often promotes health care reform, professing to welcome input from all interested parties.(12) It is revealed later the person in authority who invited others into this discussion had a predisposition toward only one answer, which then comes out in the end as a decree. This is similar to what can happen in dysfunctional families. In a court of law, evidence of such a predisposition on the part of the judge or the jury is grounds for having the verdict dismissed and a mistrial declared. In some families who define themselves as democratic, with no generational boundaries and no parental-marital differences of opinion (a pathological premise to begin with at that), there are sometimes discussions about such things as to whether, when, how, and where, the family members will take a vacation. Everyone, children included, presumably has equal input and status. At the end of the discussion, one parent may say, "Now, when we all go on vacation in July, I'll make the reservations for the hotel, and arrange for the plane tickets," as if no discussion had taken place. This controlling parent makes this pronouncement as a fait accompli. The analogy to health care reformers is obvious.

The Changing Physician

A final word about the changing role and attitude of the physician. The increased dependency of both physician and patient on the insurer, and the splitting occurring, not only undermines the power inherent in the patient-physician relationship, it also subtly alters the attitude and behavior of the physician.

Feeling demoralized and disempowered, aware of the lessening of patient trust and appreciation, and caught up in dealings with the insurer, the physician may come to feel scapegoated, less like a physician, and more like a technician, a commodity or a businessman. The physician feels hurt by accusations that he, as part of a group of people who have devoted their lives to caring for the sick and suffering, is not compassionate and that the compassion he expresses in seeing, for free or at a reduced fee, patients who are unable to pay (i.e., physician's time honored charity), is being questioned by those who complain that the cost of this falls on the paying or insured patient.

In consequence of the above, the physician's attitude toward his calling and toward his patient can change in the direction of less caring. Fearful of malpractice suits, he may begin to practice defensive medicine. The tension between the physician and the insurer escalates and is reciprocally reinforced as each homeostatically tries to offset the other's moves or anticipated moves.

Next, the physician himself may surrender to the insurer as he comes to regard it as more important and more powerful than either him or his patient. Threatened in terms of his own survival, the physician may become more preoccupied with money than with the values he believes in, and less occupied with the care of his patient, ironically proving to the patient and the insurer that he possesses the unbecoming commercial and meretricious trait that he has often been accused of having.

The patient-physician relationship further deteriorates as the patient reacts to these changes in the physician. The situation has shifted from a triadic system of adult contractual relationships to one resembling a dysfunctional family system in which one parent in the triad has abdicated adult responsibility to the other parent by whom the child is cared for at the expense of his individuality.

In this process the patient has lost sight of the fact that he, by colluding with the controlling insurer, may be losing the freedom to choose his physician, and the freedom to interact with his physician in terms of trust, expertise and privacy. He may be losing, in the aggregate, the presence in society of a certain type of physician, who may be replaced by one who is akin to an employed technician.

Although on the surface the patient may be seeking competent, caring physicians, he unwittingly is eating away at the emotional and financial investment involved in the ongoing creation and maintenance of physicians in our society, losing the very caring and competent physicians he says he wants, just as a splitting, hypercritical and unappreciative child can contribute to his loss of parenting.

The patient, the colluders among the medical community, and the third party payers, are all losing their identities, their sense of self, and their freedom to choose to interact with one another as adults.

Ways To Improve, Not Destroy, Our Health Care System

There are ways to improve our health care system other than to have non-physician bureaucrats turn it and the whole of society into a replica of a dysfunctional family.

A case can easily be made that quality of care has been impaired by some third party insurers who, in the name of quality of care, are making unconscionable profits by restricting care and limiting reimbursement. To this add the soaring cost of malpractice premiums, excessive malpractice awards and legal defense, the cost of defensive medicine, the cost of keeping abreast of regulations through the purchase of numerous manuals and attendance at seminars aimed at teaching physicians how to help their patients or themselves get paid by third parties, and the cost of excessive paper work and secretarial help.

We can help the poor receive medical care. Many programs have been doing this for some time. Unfortunately, we have already demolished many of our excellent municipal and state hospitals that provided them with care.

We can also promote through tax changes the working citizen's ability to save and pay for medical care. It is inequitable to the rest of the citizenry that employee medical benefits are not taxed while the self-employed and others can only deduct a part of their medical costs. We can change malpractice laws.

Insurance plans can be constructed that provide portability so employees will not be locked into jobs they don't like. The unions have been remiss in not pushing for this for workers, and the individual employee has been gullible in assuming, just because "benefits" are non-taxable, that he is getting a good deal.

We can do many things, and institute ideas yet to come, that can help the citizenry receive high quality care and can improve our medical system without converting it into a replica of a dysfunctional family system and destroying the freedom of the citizenry in the process.

References

1. Hayek FA. The Road to Serfdom. Chicago, IL, University of Chicago Press, 1944, p.155.
2. Ibid., p.157.
3. McCaughey E. No exit: What the Clinton plan will do for you. The New Republic, February 7, 1994, pp. 21-25.
4. McCaughey E. She's baaack! The New Republic, February 28, 1994, pp. 17-18.
5. Starr P. The Social Transformation of American Medicine. New York, NY, Basic Books, 1982.
6. Sonne JC. Insurance and family therapy. Family Process 1973;12:399-414.
7. Stelzer IR. What health care crisis? Commentary, February 1994, pp. 19-24.
8. Sonne JC. Triadic transferences of pathological family images. Contemporary Family Therapy 1991;13(3):219-229.
9. Sonne JC. The family image and ethnic conflict. Mind and Human Interaction 1995;6(1):2-8.
10. Marcovitz E. Equality. The Journal of the Philadelphia Psychoanalytic Association 1977;4:87-108.
11. Scherzer A. The holocaust museum: Lessons for American medicine. J Med Assoc Ga 1994;83:1-11.
12. Chapman AR. Exploring a human rights approach to health care reform. American Association for the Advancement of Science, Washington, DC, 1993.

Dr. Sonne is a psychoanalyst and family therapist, a Senior Attending Psychiatrist and former Director of Family Therapy Research and Training at the Institute of the Pennsylvania Hospital, and Emeritus Director of the Clinical School of the Family Institute of Philadelphia. E-mail: [email protected].