Reflections on "John Q": Simple Message, Missing Perspectives
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This article is a critical reflection on the film John Q (Burg & Cassavetes, 2002). The author explores the public perception of current U. S. health care, the distinction between medical care and health, and the ethics of health care decisions.
Key Words: Health care, health insurance, medical ethics, film criticism.
Mary Kelly, RSM is Assistant Professor and Chair, Health Care Administration, College of Health Professions, University of Detroit Mercy, 8200 West Outer Drive, Detroit, Michigan, 48219. Electronic mail may be sent via the Internet to firstname.lastname@example.org
When working parents discover that their son needs a heart transplant, they turn to the insurance provided by the husband's employer. The astounded father can only say "But I have insurance," in response to the news that the critical transplant is not covered. His next panicked move is to convert virtually all of the family's saleable assets to cash to meet the hospital administrator's requirement of an up-front deposit to assure a place for the boy on the transplant list. The amount of cash raised falls short of the mark, and time is running out. Prompted by his wife's plea that he "do something," John Q arrives at the hospital Emergency Department ready for action. He gains control with a gun (Later, we learn that it is unloaded), pulls chains from a duffel bag to padlock the doors, and makes it known that in exchange for the release of hostages, the administration is to grant permission for his son's heart transplant. In the end, the near-sacrifice of John Q's life and the apparent threat to other lives—coupled with administration's eventual willingness to put the son on the transplant list—create an improbable resolution that permits the boy's survival.
For movie watchers able to suspend their disbelief, identify with the human dynamics of the story, and tolerate a one-sided caricature of health care—particularly with respect to HMOs—John Q provides suspenseful entertainment. In response to its absence of thoughtful critique on the shortcomings of the of the U. S. health care delivery system (arguably, not the task of this movie), viewers may wish to consider the central issue of the movie from a more ordered perspective. The plot revolves around the struggle of parents to provide extraordinary medical care for their child—a task that seems nearly impossible in the current U. S. environment. The purpose of this reflection is to provide a more nuanced context for viewers who want to think in greater depth about family responsibility for health care.
A fundamental question that must ultimately be answered is Who is responsible for the health of John Q's son Michael? The movie at least introduces the likely players: parents, employer, government, and the health care system. A second dimension of this question quickly becomes apparent. When treatment for a health threat is as costly as a heart transplant, exercising responsibility for the child's health is immediately coupled with the practical reality of ability to pay. No family of modest means could withstand the cost of a catastrophic adverse health event such as heart transplant surgery. Paying for services as individuals (private pay) becomes unrealistic for any but the wealthiest in society. In the absence of a national health care program, the options for payment for services are therefore reduced to employer-paid health insurance and government programs for the indigent. Although responsibility for arranging for treatment theoretically might be assigned to the family of the person in ill health, the practical reality is that high-cost treatment is inaccessible to most families.
In the U. S., health insurance—for those covered by it—is employer-based. The basic premise of insurance is that people are grouped into heterogeneous risk pools based on something other than their state of health, such as their place of employment. The cost of the uncertain risk of illness is spread across the group: Some group members will be in good health; others will experience poor health. Underwriters determine the charge to employers for their employee subscribers, based on risk factors. By specifying whether conditions and services are covered or excluded, employers further protect themselves from catastrophic cost in individual cases. The heart transplant that Michael needs happens to be excluded by his father's insurance contract. So, in the case of John Q, although the family is insured, there is no funding for the transplant because the insurer has excluded it as a covered service. After that fact emerges, the father then explores coverage by government programs and possible donation of services by the hospital. It is only when neither of those is available, that the father takes on the system in order to force provision of the transplant.
A multitude of additional questions can be identified in relation to this case:
- Who is responsible for the health of our children collectively?
- Who decides how health care resources are allocated? To what extent are employers responsible for the health of their employees?
- In a society that allows employers to assume responsibility fo r health care coverage, what accountability is appropriate? Is the employer's role gratuitous?
- Government takes only a partial role in provision of health care. What is its responsibility?
- Do those in society who have access to greater resources and greatest capacity to absorb risk have greater responsibility to assure health benefits?
In order to begin thinking about these questions, some basic distinctions are helpful. As a starting point, are we thinking about medical care as a right or as a commodity? If we view it as a right, then health care can be thought of as analogous to public education. In that case, each citizen has the right to a certain amount of education/ medical care. Free public education up to grade 12 is provided for those who wish to attend and because of its importance, it is mandatory up to age 16. When medical care is seen from that perspective, public policy would have to determine the limits of "basic medical care." What would be comparable to "grade 12"? The amount or type of service available to each person becomes difficult to determine, since all citizens do not start out in life with equal amounts of health.
A related consideration is the distinction between medical care and health. What consumers want is health; what is available is medical care. There is no way to avoid or completely control the risk that medical care, even when delivered flawlessly, may not result in health. People who receive poor or no medical care are sometimes healthy; others who receive the very best medical care die. In considering medical care as a right, then, one basis for determining how much of it should be available to members of society might be equity. An equity approach relies on the judgment that the system would be fair or equitable if criteria based on individual need determined the amount of care available to each citizen (Aday, Begley, Lairson, & Slater, 1998). Although many complex ethical issues arise from these thoughts, the core idea appeals strongly to common sense: Different people have differing medical needs. At some point, however, whatever the basis for distributing medical care, it is likely that available resources cannot stretch to cover all of society's medical needs. When medical care is seen as a right, the inevitable public policy decision is how much medical care do people have a right to? In John Q, the answer to this complex consideration is simplified—as it would be in any individual family situation—to the assumption that each of us has a right to all the medical care that would be helpful. In reality, the thoughtful writings of ethicists and a national public policy debate have yet to bring our best collective thoughts to that answer.
Returning to basic distinctions, what additional perspectives must be considered if we were to take the opposite position and think of medical care as a commodity, rather than as a right? From this point of view, purchasing medical care is analogous to purchasing a new queen-size bed. If a consumer prefers the bed to other available goods and services in the marketplace and has the resources to purchase it, the sale results and the bed is delivered. The consumer maximizes his/her utility because the new bed is part of the ideal bundle of goods and services that matches this consumer's taste or desire. Collective preferences of consumers with respect to queen-size beds result in market demand for this item; supply and prices adjust accordingly, guided by the invisible hand described by economist Adam Smith over two centuries ago.
However if medical care is seen as a commodity, it is certainly a unique one. For example, the issue raised earlier applies: the intention of the buyer is to purchase health, but only medical care is for sale. Demand for some medical care services is highly inelastic: consumer demand changes very little in response to increases in price. That may be because the consumer prefers the medical care at any cost to the perceived alternative of ill health or death. It might also be because the consumer does not pay the full price for the medical care; in many cases the consumer payment is only the co-pay portion of total cost after an annual deductible is met. Insurance protects the consumer from the full impact of the cost, thwarting to some extent the market-regulating action of the "invisible hand."
In a society such as ours, it is the employers and the government who are the primary purchasers of medical care services. Decisions about covered services are made by the employers who pay for the greatest proportion of the cost of medical care, not by the employees. This is the basis of John Q's lack of power: he is the victim of an economic setting where he is simply not able to function as the purchaser of the needed services because that role has been assigned to his employer. With respect to decisions about provision of medical care for John Q's son Michael, there is a life-threatening misalignment of the answers to the following questions that identify three key roles:
- Who is responsible?
- Who decides?
- Who pays?
The seriousness of this misalignment can be seen when we consider the value of what is at risk and the extent to which each key player is willing to pay to prevent that loss. The parents who are most invested in the outcomes of the health needs of their child are most powerless to address them, given the expense and complexity of the transplant. For the gain of his son's healthy normal life, the father would give his own life. To assure the same gain, the employer would do nothing. The employer's general insurance coverage agreement, forged with no particular child or family in mind, says that no life is worth the cost to this insurance plan of a heart transplant. Because the employer pays, it exercises the role of decision-maker in this situation. The unaddressed third issue is whether or not the employer has responsibility for the child's medical care at this complex and costly level. From the perspective of self-interest, would an employer lose less in productivity and gain more in employee loyalty if workers do not suffer the loss of their children?
In addition to the employer, how does the society value the life of the boy? No timely exception to the rules about lack of coverage is made available by the social worker with whom John Q speaks. Would it be different if Michael were not African American and lower middle class? A study released in March 2002 by the Institute of Medicine reports that racial and ethnic minorities receive lower quality care than whites even when insured (Smedley, Stith, & Nelson, 2002), suggesting that racial disparities influence availability of care to minorities across economic strata. What would the government give to save this child's life? More importantly, what is the perceived loss to the community if this child dies? The film is silent on such issues.
Economics defines the basis for some of our collective decisions about the availability of health care resources for those in the collective societal family. Basic microeconomic theory suggests that each consumer uses his/her wealth to pay for the goods and services of greatest utility to him/her. The societal supply or demand curve is simply the aggregate of all consumer utility curves. Ms. Anderson may value a new hairstyle more than she values a co-payment for a cholesterol-reducing drug; Mr. Johnson, may prefer a carton of cigarettes to his blood pressure medication. Their choices will figure into the collective picture that affects the supply and demand of pharmaceuticals, hairstyles and cigarettes. Self-interested utility is the force behind the "invisible hand" that Adam Smith describes as the regulator of an economy beneficial to society as a whole.
Another perspective that holds promise for modifying the dynamics described in John Q is an alternative view of consumer utility. In The Economics of Health Reconsidered, Tom Rice (1998) describes a consumer whose utility is realized when others in the society have their need to receive medical care met. An example of this broader definition of utility is the willingness of people to recycle, a commitment that does not seem to be in their self-interest, yet benefits society as a whole. Some people realize satisfaction (an intangible form of utility) from enabling others to receive care. Members of the human community that understand "the common good" realize that they do benefit individually from efforts that positively affect all of us. The source of this non-individualistic form of utility is related to the understanding that as members of society we have access to certain benefits and also have certain responsibilities (Mooney, 1996).
If health care economic policy in the U. S. were redefined with that theory as its basis, the plot of John Q would be drastically altered. The goals of the hospital administrator, employer-paid insurance company and social services agencies would be aligned: providers, insurers and custodians of the welfare of the society would marshal their extensive resources to aid the child and his parents, propelled by the realization that the children belong to all of us and the loss of any of them is a loss to the whole human family.
Aday, L. A., Begley, C. E., Lairson, D. R., & Slater, C. H. (1998). Evaluating the healthcare system effectiveness, efficiency and equity. Chicago: Health Administration Press.
Burg, M. (Producer), & Cassavetes, J. (Director). (2002). John Q [Motion picture]. United States: New Line Productions.
Mooney, G. (1996). A communitarian critique of health (care) economics. Vancouver: International Health Economics Association.
Rice, T. (1998). The economics of health reconsidered. Chicago: Health Administration Press.
Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, D.C.: National Academy Press.