Commentary: Be wary we don’t go too far even as we pursue healthier living

SINGAPORE: When Health Minister Ong Ye Kung spoke of Healthier SG in March, he described it as “the next big step” in Singapore health policy. The Government’s White Paper is an ambitious document, marking the biggest overhaul of how healthcare is delivered to people in Singapore in 40 years.

What is driving this change? Singapore is an ageing society, where people are living longer but age-related and lifestyle-linked chronic illnesses are increasing.

This causes diverse personal and social challenges. People battle a wider range of longer-term health problems into the later years of their lives, productivity levels drop and healthcare costs spiral.

The solution to these changes is now commonly seen in terms of the “healthy longevity” paradigm. Healthy longevity commits to a life-course approach that can increase the number of years that people are able to enjoy in full health.

In practice, the focus is on preventing the onset of disease in the first place, rather than treating illnesses as they arise. Healthier SG embraces this vision of healthy longevity to the full.

There is much to celebrate in this new blueprint for healthcare. The pivot away from hospital care to building up health infrastructure within the community supports the goals of preventative medicine.

Integrating healthcare services into the fabric of our communities also better enables chronic illnesses to be more effectively managed over the long term. The value of a single and consistent touchpoint for receiving healthcare – the family doctor – is well-recognised around the world.

THE DOCTOR WILL SEE YOU NOW

Under Healthier SG, family doctors are being tasked with implementing better health outcomes for the population. This is striking because the goals of public health and the goals of clinical practice diverge in important ways, with each being underpinned by distinctive ethical frameworks.

Take the example of smoking. With an established political mandate, it can be ethically justifiable for the Government to introduce public health policies that aim to maximise health outcomes for the population. This might involve restricting access to cigarettes, informing people of the health risks, or nudging them towards making healthy lifestyle choices.

But, in the context of a consultation between a doctor and a patient, the doctor’s responsibilities are importantly different. The duty to act in their patient’s best interests means that they would be justified to inform the patient about the risks of smoking, and to encourage them to take steps to reduce their dependency on cigarettes.

But, if the smoker wishes to continue to smoke, the doctor is limited in what else they can do. This is because the doctor is also ethically required to be responsive to the values held by the patient, and to shape the healthcare decision-making process accordingly. Threatening, manipulating, or coercing the patient to stop smoking would not be ethically defensible.

Doctors can therefore find themselves in a curious bind. They are under a duty to take steps to bring about improvements in the population’s health. And they are also under a duty to meet their individual patients’ needs and to be responsive to their values. Frequently, these duties will pull in different directions.

THE RISK OF “HEALTHISM”

This ethical tension comes to the forefront within two central components of the Healthier SG framework: Health plans for residents and the rewards-based health points system.

The health plan is an innovative and formalised process of documenting planned lifestyle adjustments and regular health screenings. Health plans are to be discussed between doctor and patient and then reviewed on an annual basis.

The spectre in the background here is what is sometimes referred to as “healthism”. This happens when people are judged through the prism of their health status, facing subtle forms of discrimination for their failure to take responsibility over their own health and to practice socially desirable health behaviours.

Healthist attitudes can be particularly dangerous if they infiltrate into the doctor-patient relationship. This is because patients are liable to feel guilt or blame if they fail to meet health targets or expectations, even if these are not set out by the doctor explicitly.

Healthism can subtly change the patient’s expectations about the healing role of the doctor – or even undermine the doctor-patient relationship entirely, potentially reducing patients’ willingness to attend clinic at all.

Addressing this ethical tension will require careful attention to be paid to the implementation of health plans on the ground. It will be important to ensure that the patient is willing to commit to this health goal-orientated way of approaching their interactions with the doctor. Just as importantly, health plans should be co-created with patients, with goals specified in light of the patient’s own health-related value commitments.

For these reasons, a one-size-fits-all, or standardised approach, is unlikely to be viable. Instead, health planning will need to be a dynamic process. Doctors should be open to health plans taking multiple forms, tailored to the patient’s own preferences and responsive to continual changes in the patient’s circumstances or life plans.

PROTECTING DOCTORS’ DUTIES TO PATIENTS

The risk otherwise is that a patient’s health identity will become written into stone. Or patients’ encounters with their family doctors will simply become exercises in directive health management, focused on meeting what we might call health KPIs.

Beyond the negative consequences of healthism, this could also undermine a partnership model of the doctor and patient making decisions together. And it could blind the doctor from seeing the need to address the immediacy of other health concerns that sit outside of the plan.

Healthier SG offers a sea change to realise effective community-based healthcare. The ethical case for this large-scale reorientation in delivering healthcare is strong. But careful thinking on implementation will be needed to ensure doctors’ duties to their patients are fulfilled correctly.

Michael Dunn is Associate Professor, Centre for Biomedical Ethics at the Yong Loo Lin School of Medicine, National University of Singapore.