Ethics and paradigms at the intersection of health, cure, care, and economy: A French vision for a world issue

Abstract

Background: Health changes with economic development, demographic changes and technological invasion are part of the adaptation of a multifaceted welfare state in crisis, shaken by economic, political and environmental issues. Simultaneously, the digital revolution accelerates and narrows the planet. Our culture, our society, and even our sciences are built on paradigms that are obvious to everyone, but not made explicit. This includes the case of health, but now some paradigms are changing quickly. Medicine is based on the Hippocratic paradigm from 2500 years ago: the diagnosis of diseases, their specific treatment and indeed, the implied contract between doctor-patient or caregiver- patient. Societal change: In a society where citizens strongly assert their autonomy, including the ageing baby boomers, the main interest of the (older) person is the avoidance of daily disability rather than the diagnosis and treatment of multiple chronic diseases. This does not diminish the obvious desire for healing but minimizing preventable disability and combining quality of life and absence of suffering implies not only the Hippocratic contract, but pushes rehabilitation, social inclusion, and participation as a life project up until the end of life. The hospital, long the centre of the health system, remains indispensable, but less central than home care. Economic pressures cause the elderly to seek the benefits of autonomy in day care and ambulatory care. Paradoxically in 40% of cases, living at home in old age means living alone. Living at home as long as possible (and why not until the end?) implies a strengthening of a collective ethic where the solidarity principles dear to Paul Ricoeur will make sense1. Changes in care: In the field of medico-social care, the separation between health care and social care is too strong for many reasons, among which are political culture, separate skills, and especially funding modalities. In France, the caesura is enormous and hampers the development of appropriate, integrated and affordable care. In age and disability, dependence on others is one of the best models of medico-social needs. It reminds us of the urgency of the paradigm shift. Broadened to its political dimension, the dependency will be resolved only through social solidarity. Economically, there must be change in its present archaic model based only on expense accounting. A need exists for inventing a new economic approach, promoting investment, productivity and creativity and keeping up with dignity in this field. This finally comes to a 'sustainable health' paradigm, which combines simplicity, the best quality, and the right price without waste. Economic constraints will include rationing. This word is still taboo among us since the Second World War. To date, health rationing is practically non-existent. Nevertheless, the cost on our health and social system is high, probably too high, and without additional investment, the value of the present health system will probably cease to exist. Without delay, we need to put the tools in place needed to create health equity, fair price, and lack of waste. This can only be done with the cooperation of citizens, professionals, and an ethical approach to both individual and collective responsibility.