Four Big Obstacles to Rational Health Policy

A few weeks ago, the Institute of Medicine released For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges.  In this second of three commissioned reports, the IOM reviews how statutes and regulations prevent injury and disease, save lives, and improve the health of the population.  The IOM examines the legal and regulatory authority for public health activities, identifies past efforts to develop model public health legislation, and describes the implications of the changing social and policy context for public health laws and regulations.

In Chapter One, the IOM notes four obstacles to more rational health policy.  These are readily adaptable to clinical medicine and to end-of-life bioethics in particular.

• The rescue imperative (or the rule of rescue). People are more likely to feel emotionally moved and motivated to act in the case of specific individual misfortune (e.g., the plight of baby X highlighted on the evening news), but far less inclined to respond to bad news conveyed in terms of statistical lives (Gostin, 2004; Hadorn, 1991;Hemenway, 2010);


• The technological imperative. Cutting-edge biomedical technologies have far greater appeal (and historically, government funding) than population-based interventions, including public policies (Fuchs, 1998;Gillick, 2007;Koenig, 1988);


• The visibility imperative. Activities that occur behind the scenes, such as public health practice, remain invisible and are taken for granted in the public sphere until and unless a crisis arises, such as an influenza pandemic or radiation threats. The other contributor to the invisibility of public health is the fact that the fruits of its labors are often far in the future (Hemenway, 2010); and


• The individualism imperative. American culture generally values individualism, heavily favoring personal rights over public goods (Gostin, 2004).