anesthesia, anesthesiology, critical care medicine, education, electronic publication, intensive care medicine, internet, multimedia, online, peer-review, regional anesthesia, trauma
A Viens. Quality of Life as a Paradigm for Health in a Developed Society. The Internet Journal of Law, Healthcare and Ethics. 1999 Volume 1 Number 1.
“Quality of life [is] an ethically essential concept that focuses on the good of the individual, what kind of life is possible given the person’s condition, and whether that condition will allow the individual to have a life that he or she views as worth living.”
-President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioural Research 1
On almost every national public affairs survey published, citizens have resoundingly cited the need to improve health care as one of the most pressing issues facing the country. Yet, absent from the discourse on the future of health care is the type of health individuals and health care practitioners should fight for. While there continues to be marked disagreement and rhetoric surrounding the extent of the “crisis in health care”, there is one fact that is not in dispute. After a very difficult period of cost-saving measures by both regional and federal governments, we are presently situated in a period of economic prosperity whereby important decisions about re-investment and maintenance of health care funding can positively change the future direction of health care in North America, and in turn our conception of
TRADITIONAL CONCEPTION OF HEALTH: ABSENCE OF ILLNESS
The fundamental goal of medicine and health care cannot continue to simply be the elimination of disease and the avoidance of death. The etiology of disease and the associated mortality and morbidity has changed the focus of medicine. In the early 20th century, acute infectious diseases such as cholera, tuberculosis and typhus were the dominant causes of sickness and death. As we move into the 21st century, the majority of diseases affecting individuals are generally chronic illness such as cardiovascular disease, arthritis and diabetes, which while treatable, presently have no effective cures. Increased knowledge, better treatments and advancements in technology have allowed us to keep patients alive who previously would have passed away. The implications of a greater proportion of the population living for a longer period of time is significant because of the proportional relationship between age and use of health care services. In addition to the view of health as the absence of illness, Daniel Callahan, noted bioethicist and co-founder of the Hastings Center has described the notion of death and the research imperative 2 promoted by this out-dated conception of health. Medicine has sought to combat all known causes of disease, and as a result of our quest to extend the lives of individuals, we have erroneously thought of health as primarily the ability to increase the longevity of the population. As a result of this change in the nature of the disease panorama, it is simply becoming insufficient to maintain the traditional view of health as simply the eradication of disease and prolongation of life at all costs. When need to explore which determinants of health actively contribute to the quality of life of individuals.
BROADENING THE SPECTRUM OF WHAT DETERMINES HEALTH
The multidimensional concept of quality of life as a paradigm for health is dependent on a variety of factors (e.g. political, cultural, physical, social, psychological). Although our physical state of health is largely believed to be defined by internal factors, it is only recently that research initiatives and public policy are reflecting the fact that there are a number of external environmental factors that play a significant role on determining the health of individuals. These factors are essential to well-being and happiness, yet are independent of the amount of money we spend specifically on the health care system.
In constitutional democracies such as Canada or the United States, political factors such as an individual’s right to liberty, equality and security are necessary preconditions for the promotion of autonomy and choice in health maters. Moreover, guaranteed freedoms allow individuals increased access to information and ability to participate in their health. Cultural factors such as education plays a very important role in the determination of health. It has been found that low literacy rates are correlated with a greater incidence of unemployment and low income and greater amounts of mortality and morbidity. Moreover, the higher the level of education an individual obtains, the better access he or she will have to healthy physical environments. The physical environment (clean air, clear water, access to natural surroundings) is increasingly becoming more important in determining the health of individuals. The increased prevalence of diseases such as asthma and cancer and the destruction of the environment are certainly disturbing trends. There is not enough research being done into the environmental factors that contribute to illness. Social factors such as employment, income and housing are further factors that contribute to determining the health of an individual. It has been established that citizens receiving lower incomes are more likely to die earlier and to suffer more illnesses than citizens with higher incomes, regardless of age, sex, race and place of residence. 3 Moreover, we know that psychological factors can contribute to individual welfare; results have shown that poorer health outcomes via psycho-neuro-endocrine mechanisms and stress-induced behaviours can negatively affect health. If we continue to disregard the above-mentioned determinates of health, we will continue to see negative individual biological consequences and a reduction in the quality of life.
NEW CONCEPTION OF HEALTH: QUALITY OF LIFE
Although we have come to realize that a great deal of medicine will need to be focused on long-term and rehabilitative care and that greater health determinates are needed to be taken under consideration to promote the best quality of life for individuals, our attention needs to moved towards translating these notions into everyday practice. We cannot continue to retain the dogmatic notions of life expectancy and disease cure rates as the sole indicator of health in a developed society.
Under this proposed paradigm shift, decisions about treatment, research and public policy in health need to be framed by quality of life considerations. Shifting the focus of defining health in this manner proceeds beyond the direct manifestation of illness to the various effects that illnesses and treatment have on daily life and life satisfaction. By centering on the subjective needs of individuals, we arrive at a better conception of what factors and programs will best facilitate the achievement of health. An individualistic view that maximizes autonomy provides patients with the ability to make decisions about what type of available health services will promote the best quality of life.
This conception endeavors to help maximize the best mechanisms to promote health, provide a better conception of the benefits and burdens of treatment a patient is willing to endure, choice between different treatments on the level of the individual patient, decisions about the initiation or foregoing of life-sustaining treatments and the ability to allow the individual to help participate in the achievement of health.
By broadening the continuum of what factors determine health (e.g. moving away from the biological determinism of the past), and by framing our research, treatment and public policy decisions in terms of providing individuals with the best quality of life, there is an opportunity to provide a health care system that is more beneficial, more responsive and better situated to take full advantage of factors that promote health. Although quality of life assessment was almost unknown 15 years ago, it has rapidly become an integral variable of outcome in clinical research; over 1000 new articles each year are indexed under “quality of life.” 4
Health is too important for “experts” and politicians to