July 20, 2025

Pulpit Message given today, July 20th 2025 at the Unitarian Universalist Church of Birmingham. For those who would prefer to listen, I attach a link to the stream of the service. The sermon begins at 37:45. The service ends rather abruptly due to a medical emergency. I swear it wasn’t my fault…

Moral Injury and Evil: American Health Care

Good morning. I’m Andrew Duxbury. I’ve been a member of this congregation for twenty-five years and when I’m not making good trouble around here, I’m a professor of clinical geriatrics at UAB. Someone decided it was a good idea for me to speak from the pulpit today. I have decided to speak about a world in which I have been steeped for more than four decades, the American Health Care system. To paraphrase Mark Twain – everyone complains about it but no one does anything about it despite becoming, as the kids like to say, problematic. So, I thought I’d take a little time to examine what that’s all about.

I’ve entitled todays remarks Moral Injury and Evil – American Health Care. I did this because, in the four decades that I’ve been part of the system – and I can’t always tell if I’m part of the problem or part of the solution – I have noticed certain issues and themes which violate the first rule of medical ethics- Primum non nocere – first do no harm. These trends seem to be accelerating these days, driven by all sorts of forces far outside the control of any one individual and, in my case, they are driving me out the door. Earlier generations of physicians felt a calling to practice as long as they were physically and cognitively able. I can’t do that. I was created by medical education for a different era of healthcare, and I find that I no longer fit. Trying to change to fit more would violate some fundamental ethical codes – it’s going to have to be new generation that carries things forward, one trained for the times in which we find ourselves.

If we’re going to talk about what is moral and what is not, I suppose we’d better define what moral means. So I went to Google, the fount of all knowledge, and asked it to provide a definition. Here’s what I got – concerned with the principles of right and wrong behavior and the goodness or badness of human character and holding or manifesting high principles for proper conduct. This sounds reasonable to me. I was raised by parents who had expectations that we would live upright lives. I wasn’t beaten over the head with religion. I was raised Congregationalist and our services were very similar to what we do here in UU but we had a cross rather than a chalice and we talked about Jesus a little bit more. But I was guided to be truthful, to myself and others, to follow through on commitments, to share, to give others a hand up when I could, to do my best and learn from my failures rather than let them defeat me. By the time I was an adolescent, I had a strong moral code embedded throughout my personality. Sin was not what you did, it was the harm your choices caused to others. (Hey – it was the 70s).

There is a good deal of soul searching going on among the thinkers in the American Health Care System regarding moral injury among health care providers. It’s been one of the main drivers that is causing workers to leave clinical care fields – and they are in droves. 20% of the workforce that was in clinical care at the beginning of 2020 no longer works there. The reasons for this are not strictly due to moral injury, the changes wrought by the pandemic are a more proximate cause, but the transgressions of various types keep piling on. Again, we should probably take a minute to make sure we’re all using the same definition. Dr. Google says moral injury is a specific type of psychological harm that results from experiencing events that violate a person’s deeply held moral beliefs and values. It can occur when someone perpetrates, witnesses, or fails to prevent actions that go against their own moral compass. This can lead to feelings of guilt, shame, anger, and a sense of betrayal, impacting their self-image, worldview, and sense of well-being. The last five years have seen a rise in bad behavior, an undermining of the scientific principles upon which American healthcare is built, a significant shift in the power structure away from the needs of patients to the needs of big data, and an out of control profit motive warping everyone’s missions.

Most practitioners would deny that they are agents of moral evil or that the American healthcare system exists for purposes other than good. Again, to make sure we’re all using the same definition, Dr. Google says moral evil, in philosophical terms, refers to harm or suffering caused by the intentional actions or inactions of moral agents, such as human beings. I would beg to differ somewhat. My personal ethical code, for instance, refuses to let me consider the effect a patient’s treatment plan may have on my personal income. I have navigated this comfortably by making the decision early in my career to always work for salary. I’ve made a lot less money, but I can sleep at night. I give every patient the same care and attention no matter what their financial means are, and I don’t make decisions based on what it might mean financially for me or my employer. I know plenty of health care providers whose decisions are much more based around maximizing revenues and tricks of billing and deciding what is the minimum they can deliver and remain within terms of contract. There are also social moral evils – various isms such as racism and sexism which have dogged the healthcare system and which continue to cause inequities – the current presidential administration wishes to punish those who point them out.

American healthcare is an odd amalgamation of scientific knowledge, historical accident, capitalism run amok, and beleaguered allegiance to the past. No one sat down and planned it to be the way it is. Even as we all despair and curse over its current structure and function, it was not conceived and constructed by idiots. It was put together over many generations by very smart people confronted with specific problems which needed to be solved. For the most part, their decisions defeated the issues that plagued their time but they were unable to foresee and project what their solutions would do over the course of decades, especially when fossilized by commerce and custom.

What we have now in this country is unique. There’s no other system like it in the world in terms of structure, cost and results. We continue to have a cultural belief in American exceptionalism in medicine. That we are cutting edge, that we can do things that can’t be done elsewhere, that this is where the rich and powerful of the world flock for treatment. And for decades, there was fact and data to back up those beliefs. Unfortunately, we continue to carry them with us, inscribed on our cultural DNA despite the world having changed significantly in recent years.

We are the only developed country who ties health care to employment. It’s a historical accident but it reinforces the concept that those who are productive are deserving and that those who are not productive are undeserving of health services. This false dichotomy rears its head in political discourse more times than I care to count and has been particularly prevalent in current budget discussions and the obfuscation of very real cuts to public funding of healthcare.

We put more money into our healthcare system than any other developed nation. Fully 16 percent of our GDP enters the health care sector of our economy. The next highest, Switzerland, spends 11 percent of its GDP. Most developed nations spend somewhere between 9 and 10 percent. We are an extreme outlier. One would think, with that much money sloshing around the system, that we would be close to the top in terms of results. Wrong. Our life expectancy is amongst the lowest in the developed world, our maternal mortality and infant mortality rates are very high and in some of our poorer areas approach those of sub-Saharan Africa. When our health system is ranked against other world health systems on access, efficiency and results, we usually end up somewhere between number 15 and 45 on the list depending on the exact measurement criteria. We’re usually down around Slovenia and Costa Rica. Who’s on top? Taiwan.

As I said earlier, none of this was created with ill intent. To understand what happened and why, we have to dive back a bit into history, going back to the beginning of the 20th century and what was known as the progressive era. 19th century medicine, to our eyes, seems barbaric relying on primitive surgical technique, a poor understanding of hygiene, a lack of anesthesia, and a medical education system that varied widely in its ability to train physicians. Some schools granted diplomas with no clinical experience or exposure to anatomy at all. Most medical treatment was delivered in the home by Granny with the help of various patent medicines that were nostrums at best and poisons at worst; they often contained significant amounts of alcohol or opioids turning a large portion of the population into addicts. The political pressures that led to the creation of the Food and Drug Administration, public sanitation projects, and the clearing of tenement slums, spilled over into the medical profession.

In 1904, in a bid to prevent the federal regulation of the practice of medicine, the American Medical Association created a council on medical education determined to improve the standing of the profession and hired the Carnegie Foundation to aid it in its quest. In 1910, Abraham Flexner, under the aegis of the Carnegie Foundation, produced a report on the state of medical education in the US. His report called for standardization of medical education based in medical science, the closure of schools that could not meet basic standards, and the selection of students based on demonstrated skill and aptitudes. Within the next decade or so, there was a major reduction and consolidation of US medical schools and a domination of the field by allopathic schools, those granting an MD degree and based on the disease model of acute care medicine. The Flexner report also emphasized that a physician was responsible for his patient and not for the community at large, leading to the split between medicine and public health which continues to this day.

Flexner’s report, while protecting the public and laying the groundwork for licensure, board certification, and the specialization system that still prevails, had some inherent flaws. Like many things of its time, it was steeped in systemic racism, advocating that African American doctors should only treat African American patients and that the needs of that community were lesser. Most of the predominantly African American medical schools of the time did not have access to the resources necessary to bring themselves up to new standards and subsequently closed severely limiting the ability of minorities to enter the profession. The Flexner report also discounted the role of women in medicine and actively discouraged the admission of women to training, something that was not to change for more than sixty years. Medicine in this country very much came under the control of and was limited to WASP men and the moral evils of racism and sexism were very much part of how the modern system was put together. Even the Jewish community was shut out but they pooled their own resources and built their own parallel institutions such as Mount Siani and Beth Israel.

As the first generation of newly trained physicians entered society in the years after World War I, America was still dubious regarding the medical profession. In the 1920s, the average household spent more on cosmetics than on health care and most treatment was still happening within the family. The new medical schools needed patients to train their future doctors and nurses and the economy of the roaring 20s was leading them to expand their physical plants and to construct new hospital facilities. Advances in asepsis and anesthesia were creating significant improvements in surgery. In 1929, Baylor University, in Dallas Texas, built a new hospital to benefit its medical education programs but were having difficulty finding patients to admit. Justin Ford Kimball, then Baylor’s vice president for health sciences, had a bright idea. He went to the Dallas Teachers Union and struck a deal. If the union would pay a flat fee monthly to Baylor for each of its members, than any member who became sick would be entitled to a stay at the hospital and use Baylor’s medical services free of additional charge. It was the first modern health insurance program and eventually changed its name to Blue Cross.

A few years later, everything changed. The US became involved in World War II. This cataclysmic event radically transformed the American health care system in a number of ways. First, an enormous number of American citizens were shipped out and put in harms way some were killed, but even more were wounded or became ill from exposure to unfamiliar disease vectors and the rigors of warfare. More and more healthy young bodies with significant pathology returned to the US allowing our medical system to study illness and injury in great depth and our understanding of pathology and how to better care for ill and wounded humans skyrocketed forward. This coincided with one of the great medical discoveries. Alexander Fleming had discovered the penicillium mold on oranges in the 1920s and its antibiotic properties were known by 1930 when it was first used to treat an infection (conjunctivitis in newborns). There was a problem, however, the means to isolate the chemical which we now call penicillin from the mold and then produce it in quantity had not yet been figured out. This puzzle was cracked in the early 1940s, shortly before the US entered the war. This new miracle drug gave the US a new weapon in the war which every army has faced since the beginning of time, that against wound infections. As it was of national security importance, research on antibiotics amped up and by the mid-1940s, they were available not just to the military, but to civilians causing a revolution in the perception of health care.

Antibiotics, which initially needed to be administered intravenously and therefore required hospital care, led to more and more people, whom loved ones would have witnessed dying at home just a few years earlier, going to the hospital and walking out. Our infrastructure, including our health system, was intact following the war while that of most other developed countries was in ruins. We were able to get the jump on everyone else and the idea of American exceptionalism in medical care was born and, within a few short years, we had developed our current acute care hospital centered system of providing care.

In addition to this, the industrial economy was heating up. American factories needed to produce goods not just for the US but for the world suffering form fifteen years of pent-up demand caused by the Depression and World War II. Jobs were plentiful and everyone was hiring. However, there were wage and price control laws on the books left over from the economic management of the Depression. These prevented employers from boosting salaries to attract talent, so they turned to other inducements which became the benefits package. By 1947, the titans of industry turned to congress and had the tax code rewritten to make it financially advantageous for employers to provide health insurance and an employment-based system was born. It took root nowhere else.

It was quickly realized that an employment-based system left out the post-employed and the unemployable so steps were taken to create legislation which would provide a federal safety net for these individuals. Unfortunately, these attempts were branded as ‘socialized medicine’ and ran into the red scare of the late 40s and early 50s and went nowhere. It wasn’t until 1964 that the political moment became right and under the Johnson administration, the major federal health and welfare programs such as Medicare and Medicaid became law. There was abundant opposition to these programs, led by the AMA who believed firmly that inserting a federal dollar into the patient/physician dyad would add a third decision maker, causing problems for both sides. They hired an out of work movie actor to be their celebrity spokesperson for their campaign against Medicare, Ronald Reagan. He found he had a knack for politics.

Fifteen years later, Reagan came to the presidency on a tide of government isn’t the solution, it’s the problem. His economic policies began a transfer of wealth upward and encouraged economic consolidation. Reaganomics hit medicine as much as any other sector. Before the creation of federal payment systems, medicine was primarily a small business operation. Physician practices were privately owned. Hospitals usually were owned and run by not-for-profit institutions of charitable mission, whether religious or secular. Medicine was by law and custom a not-for profit-enterprise which existed for social good. In 1974, when Richard Nixon, at the behest of his old friend Charles Kaiser, signed the HMO act, he opened the door for private enterprise to purchase and make profit from entities providing medical service. Reaganomics put this move on steroids and by the mid-1980s, for profit hospital chains and insurance companies began to dominate the market. Wall Street took notice of the amount of money that could be gleaned from the system. It came calling and an earlier generation of clinicians sold out for personal profit.

Since the 1990s, the trend has been consolidation, corporate ownership, additional layers of management such as pharmacy benefit managers which add complication but do little to actually improve healthcare. The rise of computers and AI has added a whole new set of complications as medicine as an entity increasingly reacts to aggregate big data and less to the needs of the individual. This has placed the physician in the midst of a moral dilemma. To whom does he owe allegiance? The patient or the paycheck? Our time is spent in data gathering and data entry (my day is becoming reminiscent of my very first job at age 15 when I was a data entry clerk and keypunch operator). The computers track our every move. If we don’t meet our metrics, we will be dismissed and replaced allowing us to help no one. I didn’t know I was spending thirteen years in higher education to learn to type.

Starting in 2020, it’s all started to unravel. I call this ‘The Great Undoing’. It began, of course, with the Covid-19 pandemic. The lack of preparation, the neglect from the highest levels of government, the trauma of provision of care in impossible circumstances, the indifference of administrative layers safely cocooned in their working from home environments led to a wholesale rush for the exits from the older generation. Everyone is short staffed. It takes more than a decade to train a doctor and almost as long to train a nurse practitioner. You can’t replace the workforce with a couple of weekend seminars and some YouTube videos. Everyone has noted the inability to get appointments and the delays in care that have become commonplace. We want to help but there’s only so many of us left to go around.

In addition to this, this past year has led to a presidential administration determined to bring down American medicine for political gain. The great institutions created from the ideals of American exceptionalism are being decimated. The research universities which create our knowledge and train our future providers are under attack and having their funds sharply curtailed. Those put in charge of our major health programs proudly advertise their ignorance of science casting aspersions on centuries of learning. I’m all for making America healthy again but throwing out the last century and a half of medical advancement is not the best way to accomplish that goal.

This leads the average practitioner open to the death of a thousand cuts of moral injury. On a daily basis we must pay more attention to a machine than to our patient, constantly try to do more with less as the money in the system dries up, argue with clerks at insurance companies and pharmacy benefit management firms to try and get what we, with our many years of training and experience, know our patients need but which keeps getting shut down by someone with a high school diploma and a company manual, endure arguments from patients and families, based not in science or logic, but on the latest misinformation advocated by media conglomerates or fueled by direct to consumer advertising, try to bolster the morale of our colleagues who may be in a worse position than we are in, have to fill out the same form for the third time because an insurance company doesn’t like our choice of wording (what part of both legs amputated don’t they understand?) and on it goes.

These moral injuries, to me, have root in moral evils. What are they? The first comes out of the old adage: Radix Malorum est Cupiditas. Greed is the root of all evil. I’m not against capitalism and I’m not against making a profit. I am against the making of money to pay shareholders being the be all and the end all of such a vital part of our lives. There is a role for the federal government to manage important sectors of our economy so that they can exist and work for the entire population. A second moral evil is our construction of a system that exists to prevent care. The ubiquitous middlemen that are now part of every decision process need to be replaced with people who understand the nature of clinical medicine and the sacred bond that develops between patient and physician which allows true healing to occur. Our third major moral evil is the rejection of knowledge, science and fact for political expediency. This one is probably the easiest to deal with. Fact is fact no matter how hard you deny it and, as will eventually happen, when something arises to bite us all in the butt because we refuse to understand how nature works and our place within natural systems, we may quickly reverse course.

So how do we fix this mess? It’s fixable but it’s going to take a lot of political will and a certain amount of uniting of the country behind a movement to accomplish this – and our current politics don’t allow for uniting over much of anything. If we eventually come around to an understanding that we are stronger together rather than on opposite sides of the football stadium, we may be able to take on some of these tasks. These include resource redirection away from administrative functions to clinical functions, a better understanding of morbidity and mortality so that we no longer hold impossible ideals like ‘death is optional’ , creation of universal data systems so that information can be quickly shared throughout the system, development of single payor mechanisms, and subsidization of medical and nursing students so they don’t enter life with six figure debts that require them to concentrate in higher reimbursement specialties.

What comes next? I haven’t a clue. Stay tuned. I’ll probably write something about it eventually. There’s only one thing of which I’m fairly certain. Retirement in 22 months. But who’s counting? Thank you.