[This Date in UCSF History] Socialized Medicine is Respectable in Norway, the UK

Originally published on September 22, 1994. This author, a graduate student who works for the Department of Otolaryngology in the Epstein Research Laboratory, spent a month this summer studying the healthcare systems of the United Kingdom and Norway.

The study was organized by a professor of philosophy and biomedical ethics at Syracuse University.

Darren D. Cooke was part of a 17-member group that conducted interviews with citizens and met with local government officials, members of the press, and healthcare providers.

In 1990 the United Kingdom spent six percent and Norway spent seven percent of their GNP and offered health care coverage to every citizen. During that year, the United States spent 12.5 percent of its GNP while leaving 30 million people uncovered.

Have these countries discovered a formula to get more for their money in health care? Yes and no.

A month-long visit to examine the healthcare systems of Norway and Great Britain revealed striking differences in the delivery efficiencies when compared to the United States.

As significant, though, were the differing cultural views toward end-of-life decisions and government involvement in the rationing of services.

Norwegian physicians and patients approach end-of-life decisions in a much different way than we do in the United States, and this viewpoint is intimately tied to government regulation of care in common hospital practice.

Prolonging life remains a value only if the time gained will be rewarding. Otherwise, a comfortable and unprolonged death seems to be preferred in Norway. A Norwegian geriatrician told us that no one is kept alive on a respirator in Norway unless they have a good chance of regaining the ability to live without it.

Patients in a vegetative state are taken off of life-support after four days, and generally without consultation with the family. Care of the elderly in Norway includes state-run homes for older patients with Alzheimer’s disease, and readily available home care and psychiatric services.

Government involvement in Norway — unlike the United States — is not widely viewed with distrust. The British approach to death falls between Norway and the United States.

While physicians generally do not share the aggressive “thwart-death-at-all-costs” mentality common in the United States, they face similar dilemmas over when to withhold treatment. For this reason, living wills, or “advanced directives,” are beginning to gain popularity in the United Kingdom.

While malpractice insurance rates continue to rise in the United States, spurred by an increasing number of lawsuits and larger monetary decisions for patients, such insurance coverage is a small expense in Norway and the United Kingdom.

Whereas an American obstetrician can pay over $30,000 annually for malpractice insurance coverage, the typical Norwegian physician pays only the equivalent of $ 100 and the British physician $1,500.

This difference does not arise from regulations or disincentives to sue, though. It was evident from meeting with Norwegian and British citizens that they appear to better accept that medicine and doctors are not perfect, which may explain why they are more reluctant to take unfavorable medical results to court.

Priorities Attitudes towards specialized care also differ in the two European countries we visited as compared to the United States. It is common in both the United Kingdom and Norway to be placed on long waiting lists for procedures beyond primary care, such as non-emergency cardiac or orthopaedic surgery.

For instance, in both countries there is a one- to two-year backlog of patients waiting for hip replacements. Resources are further rationed in Norway with a waiting list priority system.

A patient may wait years or never even receive a particular procedure because his or her problem was not urgent enough to earn a position on a higher priority list.

In the United States there is not a long wait for such care, but a form of rationing does exist in that only those who can afford health insurance will receive such care. The citizens of the United Kingdom and Norway with whom I spoke said that they are on the whole happy with their health care.

They appreciate the low personal cost and the social implications of health care being available to all. Their complaints tend to be about waiting lists and lack of high-technology care. The socialized governmental policy in these countries feeds the people’s cultural outlook and is itself shaped by it.

That is, in a democracy, state policies reflect the will of the majority; simultaneously, living with such policies may cause people to expect and value social support systems.

While much may be learned from the United Kingdom and Norway, differing healthcare expectations —and a culture that glorifies individualism— make it likely that Americans would have difficulty accepting similar practices here.