MED-NET Conferences 1998, Lille & 1999, Maastricht
Anthology of presentations 4.2.

Tensions between European legislation and national developments in health care. Implications for medical education.

G. van Heteren (Nijmegen, The Netherlands)

Recently, in preparing several articles about the growing pressures in European health insurance and Europe's pharmaceutical industries, it struck me once again how little - on the whole - the mounting tensions between national and international developments in health care systems are discussed with medical students, for instance in the context of programmes of social medicine or introductory courses to health care systems. To specialists who take an interest in Europe and health care it is fascinating to watch how rapidly issues of health care politics, financing and control are being moved to European fora. This despite the fact that officially - according to the European Treaty - health care is still under the governance of European member states. It is in part due to the formally upheld division of power regarding health care between the EU and the member states, that the European debates on health care matters take unexpected turns, and often seem to escape mature democratic control.

A striking feature of the European medical arena today is its uneven composition: with a dear predominance of European lawyers, health insurers, industrialists and health care entrepreneurs, that stands in stark contrast to the relatively modest participation in the European debate of health care providers, medical academics and medical educationalists.

Considerations of this kind have forced me to return to an issue that time and again, medical educators have pondered over: do educationalists focus enough on the forces of change in medical and social environments; do we prepare our students enough for the world in which they will finally have to work? Surely, these are old, familiar worries, but they continue to plague us. In this paper, 1 will begin to address these questions by placing them anew within the context of a longstanding European debate about the focus and contents of European medical education.

Subsequently, I will introduce two cases of structural developments currently underway in the European medical arena. Developments of which I'm sure most medical students have never heard, but which might have far-reaching consequences for their future medical practice. I have selected the two already-mentioned cases: the case of Europe's changing health insurance situation and that of European pharmacological and biotechnological research and development. These cases are but examples of a much wider array of European issues that could serve similar purposes: to illustrate new European developments, while national governments' desperately attempt to keep a tight control over national health care expenditure. I will first comment on the general significance of the two cases, before moving on to the broader issue of how we are to decide which European developments should receive closer attention in the critical formation of European medical students.

I.

The problem I wish to discuss with you could be formulated in broad (some might say far too broad) terms as: "Is it the task of medical educationalists to prepare students for the wider world in which they will have to function, and if so, how?" Worrying about the social, cultural or political relevance of medical education is certainly not a new, 1990s phenomenon. Especially not in circles of people with a medical humanities background. Ever since the rise of modern medicine, the question of medicine's social impact and importance has always been high on the agenda of medical educationalists, and even today, it remains amongst the toughest questions with which many teachers of medicine feel they are confronted. Historically, there have always been prominent physicians, who have answered the question as to whether medicine had a social and political role to play with a whole-hearted "Yes". Some even went as far as supporting the view that - above all - medicine was a socio-political science.

For example, 150 years ago, during the turbulent months around the 1848 revolution, the famous German physician Rudolph Virchow, best known to posterity for his fundamental research on cellular pathology, left no doubt as to medicine's social and political pertinence. In a radical journal called Medizinische Reform (Medical Reform), Virchow - as chief editor - indicated regularly how he thought medical students needed to be prepared for the critical responsibilities which modem society had given them.

Commenting on the rapidly changing socio-political and socio-economic conditions in Europe in his own days, - with the rise of a liberal bourgeoisie & in medicine the articulation of a new public health ethos - Virchow wrote enthusiastically: "a movement unparalleled in the history of the world has taken us from dynastic and territorial politics, i.e. from pure politics to social politics, to national democratic politics. This movement will not come to an ultimate halt until we have attained a cosmopolitan point of view, that of scientific polities, that of anthropology or physiology (in the widest sense)..."

Virchow expressed his contempt for colleagues who remained naive enough to believe that they could stay aloof from the major social changes Europe underwent. He mocked anybody who thought that medicine had nothing to do with such social developments or politics. And he deeply pitied all those who - as he phrased it – "hoped to endure the storms of world history by timidly taking refuge in personal or professional circumstances." He warned against those simple souls who attempted "to judge the strivings of those who dare to sail their ship in the storm of world history from the paltry viewpoint of their clique and their person." For Virchow, medicine was above all a social field of key importance, right in the middle of some major social transformations. In hundreds of polemical speeches, articles and editorials, culminating in a short party-political career, Virchow contributed extensively to giving form and shape to the liberal ideas that stimulated medical reformers by the mid-19th century. Europeans today owe it in part to energetic doctors such as Virchow, that within many of our own medical schools, course programmes now standardly include subjects such as social medicine or public health & hygiene.

Of course, over the last 150 years, these subjects have developed much further, often in close connection with other medical humanities interests: with medical history, philosophy, anthropology, ethics and law. All these disciplines together provide our medical students with the academic means by which the complex problems that cause modem people to suffer and fall ill can be analysed. Add that to the fact that modern students have swifter access to a variety of modern media, embark more easily on study-trips and generally move around much more freely, and one could argue that educational conditions have improved considerably since Virchow's time. It would certainly be possible to defend the view that by all these formal educational experiences, a modern medical student is better equipped than his 1 9th-century counterpart for the world he/she lives in.

However, there lies great danger in too much complacency. We still live in turbulent times, and from certain perspectives it might seem that in all this century, Europeans have learnt very little. Even if in our medical educational programmes today we do not completely exclude medical humanities approaches, we can still observe how in the buzz of day-to-day medical life medical humanities lines of questioning are often quickly marginalised and replaced by quick-fix, technical and pragmatic forms of thinking and dealing with problems. Moreover, not all medical humanities teachers live up to their own critical obligations. In my view, they should not shy away from continuing to ask the types of questions which medical critics such as Rudolph Virchow felt adamant about. We will never be exempt from determining which developments in medicine and the world require close critical scrutiny within medical education. We have an obligation to keep the critical vocabularies alive which might assist us in our critical examinations. My remarks might sound extremely basic, but it is precisely my concern that in the competitive pressures of day-to-day survival, and in our often too reactive behaviours we loose sight of the basic issues. Questions such as: do we select the most important current developments in and around medicine for critical analysis in educational programmes? How do we make critical enough selections of topics? Are we still employing criteria of social, socio-cultural or socio-moral relevance in selecting subjects for teaching and critical debate, or have other kinds of selection-criteria taken precedent, such as the criteria of immediate commercial success?

In order to elaborate on some of these points, I would like to turn to two recent examples of complex health care developments today, which to my mind do underscore the importance of ongoing medical humanities scrutinising and criticism.

They are: the cases of health insurance developments in Europe today, and that of the current movements inside Europe's pharmaceutical industries. Although apparently rather dissimilar cases, they share a number of characteristics:

• both cases point at a fundamental reconfiguration of (political) power concerning matters related to health care, with shifts from national to supra- and transnational levels
• both cases are dear indicators of the pressures put on European social welfare ethos in health care, pressures that move matters in the direction of private & individualistic sense of responsibility as core value, overtaking traditional European notions of social solidarity
• both cases show how rapidly and without much public debate medical objects and practices are being reconfigured from social goods into commercial/industrial goods. One only has to think of the concerted efforts of biotechnological industries to get biological materials patented to develop a sense of what I'm talking about.

II.

At this conference we have heard a lot about supra- and trans-national health care, different Euregional initiatives, cross-border collaboration and the mobility of medical personnel. Medical mobility, many expect, will be stimulated further by the completion of the European internal market. But, as many observers point out, mobility is still hampered by the fact that in the European Treaty, social systems and health care are considered the responsibility of national regulators (art. 3 Maastricht /art 129). National regulation of growth of health care expenditure is often defended by referring to the protection of the European values of equal access, solidarity and affordability of health care, supposedly defended by national rules. Even though historically, many agreements have been developed between neighbouring countries to guarantee the well-being of persons who work across the borders, and, equally, a range of international or bilateral agreements exist between nations of the EU to protect their citizens when they would fall ill abroad, on the whole, social insurance legislation is still nationally designed and implemented.

In the strange social policy vacuum that thus exists at the European level, it is the European Court of Justice that has gradually been manoeuvred into the role of arbiter. The ECJ has become the main judge in a growing number of conflicts in which the demands which Europeans can now make on the basis of internal market legislation clash with the rights that national member states still claim to organise and control social security budgets and health care expenditures. From the rapidly growing list of cases before the European Court of Justice, my first example stems. It involves two recent Court rulings which clearly demonstrate the possible tensions between European internal market legislation and national social policy. These cases have become widely known as the Decker / Kohll verdicts. Before this audience, a brief summary of what Decker / Kohll amounted to will probably suffice. A Luxembourger, Mr. Decker, bought a pair of glasses in Belgium without informing his insurance company in Luxembourg. For these glasses, he was not reimbursed, since the Luxembourg sickness fund maintained that Mr. Decker should have asked permission beforehand. Around the same time, another Luxembourg citizen, Mr. Kohll, sent his daughter to Germany for dental care. 11e had asked permission from his insurance company beforehand but not obtained any, since his Luxembourg insurer did not deem this dental treatment 'emergency care' Kohll and Decker brought their cases before the European Court and won. The Court ruled that the basic European rights to free movement of goods and services had been violated by the insurance companies' refusal (art. 30/36/59/60 EU -Treaty). European patients were entitled to travel abroad for regular (extramural) services which were covered by their insurance policy, up to the amount of money which the insurance would normally have paid in the country of origin, and as long as the actions of patients crossing borders would not jeopardise the financial stability and quality of care of national health care systems.

The Court's rulings first provoked considerable panic, which was followed by extensive debate amongst EU's health insurers and national policymakers. By contrast, European lawyers could not understand the fuzz. They pointed at a series of similar cases over the last decade or so, and were actually more surprised that it had taken social policy experts so long to catch up with the realities of European economic/internal market law and its implications. Several major conferences were organised last November in Luxembourg, in which the hottest issues surrounding the Decker / Kohll cases were quickly articulated:

They involved the following questions:

1. What impact will further European internal market regulation have for the legal status of the doctor -patient relationship, and the relation between insurer and insured (private law/social law)
2. What will become the final status of medical goods and services in Europe? (are they social/industrial or commercial goods?)
3. What would/should be the extent of freedom of movement of patients & other participants in field of health care (patients/clients/customers; health care providers/entrepreneurs)
4. Will the historically grown differences between health care systems be maintained, or will further convergence arise, and if so, in what direction?
5. How long will differences between social insurers and private insurers remain visible within European social insurance based systems? What ethos will finally prevail?
6. What are the implications of rulings such as Decker / Kohll 3 -based on European economic law for already existing forms of European social legislation?
7. Ultimately, what will be the relationship between European economic and social legislation in the sphere of health care?

Why am I bothering medical educators with all this? The answer is simple. No matter what the outcome of the above will be, it is dear, that many of these issues do have direct implications for the professional work climate of future practitioners in Europe's health care systems. The question which should therefore occupy medical educators is: what would students have to know about such European affairs in order to be better equipped to follow critically the processes that currently shape their future work environments?

III.

My second example tells a similar tale. It is taken from the fascinating domain of pharmaceutical and biotechnological research & development. I assume, everybody in this room}s aware of the heated disputes inside European nation-states about the formidable growth of expenditure on pharmaceutical products. Most Western countries face expenditure-rises on pharmaceutical consumption which cannot merely be accounted for by referring to demographic changes, greying of the population or policy shifts to extramural care which involves greater consumption of pharmaceuticals. Pharmaceutical growth (EU official 6-10%), most critics agree, should also be seen in terms of the pressures put on health care systems by a heavily competitive industrial sector in which - some critics believe - only eight global players will survive in the next ten to twenty years. EU-pharmaceutical industries produce 40% of the world's pharmaceuticals, the EU-market is good for 30% of the consumption of the world's pharmaceutical output. 487.000 persons find employment in the pharmaceutical sector in the EU, 71.000 of whom in research & development. 90 billion ECU was spent in the EU in 1997 on pharmaceuticals, 2/3 of which (56 billion ECU) paid for by social health insurance schemes. In short, the pharmaceutical industry forms a powerful economic sector, with strong incentives to produce and compete. So naturally, national health policy makers should be concerned.

For many years now, especially the R&D related pharmaceutical industries, organised in the European lobby EFPIA, have put pressure on European legislators to improve industrial, competitive conditions for them. Quite understandable from an industrial perspective. Thus, over the last few years, three important round-table conferences have been organised by Europe's Industry-Commissioner Martin Bangemann (German and liberal), which together form a pointed illustration of the complicated tug of war between industries, worrying member state health politicians and internal market Euro politicians who note that the industry seems to want protection and freedom at the same time. To discuss all the details of these negotiations would lead too far, but the war that is waged in the backrooms of the European Commission and lobby organisations conveys one basic question, which in my view concerns everybody in health care, i.e.: Can the international industrial concerns and those of health care ever be unified in one policy. Can health care goods also be industrial goods, and if so, how?

Seen from the European level, it is a bit pathetic to observe how national governments within the context of their national mandate, still try to formulate regulatory mechanisms. Because as soon as we move the spotlight to Brussels and beyond, we see industrial forces attempting to reconfigure the status of medical goods and services with much more interest and force, turning medical goods into simple industrial products and services in their attempt to have EU industrial regulations apply rather than national controls. Although of late, the European Commission seems to have become a bit more sympathetic towards the worries of the nation states and their 'legitimate right' to impose pharmaceutical controls, it is unclear what the mounting pressures in the pharmaceutical realm will result in the end. Again, why would it be important for European medical educators to devote more critical attention to such processes? Because they shape the future. The medical students of today, once they finish their studies will either find a Euroland with still strong national control mechanisms on medicines and pharmaceutical products at the expense of the fact that pharmaceutical industries have moved most of their R&D to other parts of the world, or a Euroland in which pharmaceutical industries have gained even greater control over the medicinal landscape and the definition of what is good pharmaceutical care. Or another scenario, who knows. But medical students should know enough to follow these formative processes critically.

IV.

Which brings me to my concluding remarks. Neither of the above mentioned cases, health insurance, or pharmaceutical developments, are static. Neither could be understood without some economic, political and social science background. Neither of these cases could be understood without some historical and social ethical background.

And both these cases touch upon the fact, that in Europe, medical and social parameters are being shifted, long before the large majority of workers in health care notice the implications. This demonstrates what I would call, the presence of a democratic gap in European medicine. And it is here, I feel, that a dear task lies for educationalists. The fact that the world has become more dynamic and complicated does not mean we should forget about some old, critical questions. Rather, we should pursue critical examination of our world with greater vehemence. We need to develop new European-wide programmes, in medical schools, which ask: which powers / interests do prevail in Europe and beyond, and which should, what worldviews, philosophical / anthropological notions, which ideas about causes / patterns of change, which insides into the moral landscape & changes in legislation. In other words: if we do not rapidly engage ourselves as teachers, in the development of new medical humanities educational programmes to prepare students to critically follow current European debates, others will decide for us. And for our students.

1. Impact European internal market regulation for legal status: doctor-patient; insurer-insured
2. Status of medical goods / services social / industrial / commercial goods?
3. What freedom of movement of patients & others patients / clients / customers health care providers / entrepreneurs?
4. Historically grown h.c.s. differences maintained or further convergence?
5. Differences social private insurers? Which ethos will finally prevail?
6. Implications of Decker / Kohll for already existing forms of European social legislation?
7. European economic-social legislation in the sphere of health care?
8. European industrial concerns Health care concerns > One Policy?

ISBN Number 90.805758.1.X

Contents of this online publication 
at this website

Download this publication as PDF file
To be viewed with Acrobat Reader
Download Acrobat software here

Order a copy of this book by sending 
an e-mail to .