MAKING POLICY THAT MAKES SENSE

A new administration has been inaugurated into the corridors of power. A
new cadre of public health elite has been, or soon will be, installed. So
perhaps there is a new opportunity to embrace the rationality and first
principles too long absent from public health policy.

The meaning of rationality is perhaps self-evident. In essence, it means
decisions and actions make sense. If, for instance, evidence shows that
sex education and the availability of barrier contraception can reduce
unintended pregnancy and sexually transmitted infections without
encouraging sexual activity, and these are socially desirable -- then
policies that advance these objectives are rational. Policies that impede
them are, arguably, not.

The notion of first principles is less immediately transparent but equally
fundamental. It means that a series of related decisions, actions or
policies should all derive from a common guiding principle, or principles.
So, for example, the principle that we should not drive after drinking
wine, beer, vodka or gin -- all relate to the first principle that we
should not drive after drinking alcohol.

Definitions dispatched, I would like to make the case that we are at best
disrespectful, at worst altogether dismissive, of first principles in much
of our public health policy -- and for that matter, much of our collective
decision making. Examples abound.

As anyone else who has passed through the rites of medical education can
attest, there is a wrestling match in every emergency department of every
teaching hospital every day over the fate of potential admittees to the
hospital. The emergency resident, responsible for immediate treatment
only, is eager to admit every patient who cannot readily be sent home, and
thus unclutter the perennially cluttered ER. The admitting resident,
however, who assumes (or delegates) responsibility for the ongoing care of
admitted patients is not only eager to deny such admissions, but actually
earns kudos from fellow residents for being "a wall."

Where in all of this are the clearly elucidated, carefully vetted and
universally accepted criteria for hospital admission? They don't exist. We
often grapple with specific decisions while ignoring the underlying first
principles on which they should be based.

There is much public opposition to the use of medical marijuana.
Superficially, this is quite sensible. Why would anyone sanction the use
of an illegal drug for purposes medical, or otherwise? But there is
cocaine in every emergency department in the country (we use it to treat
severe nosebleeds). There are narcotics, some of which are close cousins
to heroin but even more potent.

Where, then, is any semblance of rationality or a first principle? Do we
ban all potentially dangerous drugs? Clearly not. All drugs that are
illicit for general use? Not that either. Do we, then, defer all such
decisions to trained medical professionals, and trust that if they can
decide when to administer cocaine, they should be able to decide when to
administer cannabis? Apparently not that either.

On the vexing topic of physician-assisted dying, first principles are
mowed down on a slippery slope of inconsistencies. Our policies favor the
option of palliative care, even if the pursuit of palliation at times
accelerates death. This all boils down to timeline: We can do what kills
as it comforts if it kills too slowly to make the link obvious. If it
kills a bit faster, it's taboo. If this makes sense to anyone, please
explain it to me.

Perhaps the granddaddy of all inconsistencies is our approach to the whole
topic of health care. Is it a right or a privilege? Rather than beat that
topic into its submission of a first principle, we continue to debate all
of the specific ramifications of failure to establish some general rules.

We all agree that the new arrival in an emergency department with a
life-threatening gunshot wound gets treated without first ascertaining
insurance status. This suggests that at least some extremes of health care
are a right. What if the wound threatens limb, but not life? Do rights
extend from the person to the appendage or even the digit? And, if so, is
it only for bullet wounds, or does it extend to the more grisly of paper
cuts? A quagmire, but one we cannot hope to escape without the consistent
guidance of a first principle decision.

Connecting this simple sequence of clinical dots impels us to the
concession that some health care is a de facto right, some a privilege:
bullet wounds to one side of the line, paper cuts to the other. That, in
turn, implies the inescapable providence of health care rationing. By
refusing to acknowledge its providence, we don't escape it -- we simply
acquiesce to it irrationally. Establishing first principles would allow
for far more rational rationing of health care than currently prevails.

I am not advocating for any particular policy. I am advocating for an
approach to generating policy, and for that matter, personal decisions. I
believe progress of all varieties is forestalled by our willingness to
assert positions not held accountable to the meanest standards of
consistency and rationality: our tendency, if you will, to shoot first and
debate gun control after.

There are innumerable hopes, aspirations and trepidations attendant upon
the current transition in power. Into this volatile brew, I cast my own
hope: Perhaps we might make collective decisions and public health
policies that actually make sense.