American medicine has mastered a perverse art: paying more to achieve less.

We call it “cost-cutting,” but it is a system of engineered backwardness. We underfund clinical staff, then spend fortunes on lawyers to defend the inevitable errors. We employ armies to process bills while insurers employ armies to deny them. We treat the eyes, the teeth, and the mind as optional accessories, as if they could be unbolted from the body whole.

This is not a system of care. It is a futility economy, where the most reliable product is not health but hopelessness: wasted money, wasted effort, wasted lives, and finally, wasted will.

From the inside, it feels less like medicine than improv comedy: everything is made up, the points do not matter, and the patient always pays for the punchline.

The logic of absurdity

Hospital staffing reveals the logic of backwardness. Positions are cut. Nurses, aides, respiratory therapists, case managers, vanish in the name of thrift. The result is predictable: more errors, slower care, higher burnout, worse outcomes. The supposed savings soon vanish into years of legal defense and payouts that eclipse the original cost of staffing. The only thing preserved is the illusion of fiscal discipline.

The math is no better in private practice. A colleague’s clinic spends $300,000 a year on four staff whose sole function is navigating billing, collections, and prior authorizations. Not a single minute of that work touches a patient; it is simply the price of survival. On the other side of the line, insurers employ their own teams to deny those same claims. The duel is so expensive that the fight itself often costs more than the care.

What looks like a failure is, in fact, the design.

Incentives of harm

The incentives are just as warped at the bedside, where the ethicist’s task becomes analyzing the morality of decisions that have already abandoned dignity. The irony is that the most wrenching ethical crises are rarely clinical in origin. They are manufactured upstream, in billing departments and boardrooms, and the ethicist is left to mediate the human fallout.

One patient languished in the ICU for weeks with no discharge plan. Medically, they were stable enough for transfer. Financially, they were not. For every day they remained, the insurer saved money, as the hospital’s lump sum payment for that “length of stay” had already been made. A transfer would trigger a new payment. So the patient stayed in limbo, occupying an ICU bed not for their health, but for an insurer’s balance sheet.

In another room, a family asked if sedation could be lifted from their dying loved one, just long enough for a signature. Not for a final moment of connection, but because the deadline for filing taxes was approaching. Without the paperwork, they faced financial penalties. Could a body briefly pulled from the edge of death meaningfully consent?

These are not dilemmas of medicine. They are dilemmas of accounting. The task, more often than not, is not to resolve them, but to help clinicians and families survive the moral injuries inflicted by a system that mistakes cost for care.

Leadership in a vacuum

The absurdity flourishes in leadership. I once attended a 7 a.m. emergency meeting on cost reduction. The flagship proposal? Counting the number of copy paper sheets used by the care management department. As frontline staff were being tasked with squeezing pennies, the senior team was finalizing travel for their upcoming leadership retreat.

In a gesture of solidarity with the supposed austerity, I rebooked my own lodging from the conference hotel to the hospital convent, offering discounted rates as the host site for the retreat. I was surprised to find only one of my colleagues had done the same. The rest of the leadership team had quietly kept their reservations at the Hilton. The convent, built for one hundred, was a cavernous, empty space for the two of us.

The lesson was clear: austerity for the workers, comfort for the executives. Backwardness was not just tolerated; it was modeled from the top down.

The core product: learned futility

Whether it is performative cost-cutting, insurance games, or leadership hypocrisy, the outcome is the same: futility.

• Staff cuts that cost more than they save.
• Administrative armies locked in a zero-sum war.
• Patients warehoused to manipulate billing cycles.
• Families prioritizing tax forms over goodbyes.

The system’s most insidious product is not just waste. It is resignation. It manufactures a deep, corrosive belief that resistance is pointless.

This is learned futility.

After enough denials are met with endless appeals, clinicians stop fighting. After enough absurdities go unchallenged, they stop questioning. Patients stop demanding dignity because they learn the math is rigged against them. And leaders settle for counting copy paper because they have stopped imagining a better model.

Burnout drains our energy. Learned futility drains our agency. And agency is the only lever we have left.

The radical act of hope

When clinicians believe their effort is wasted, advocacy dies. Patients suffer not because the right care is impossible, but because the system has convinced its operators that the fight is not worth it. Hopelessness becomes the default, and an entire profession drifts into compliance. The tragedy here is not fiscal. It is clinical: a system that itemizes every expense while writing off human dignity as an acceptable loss.

This is not a broken system. A broken system fails by accident. This is a system functioning as designed. A machine that runs on absurdity and is fueled by our resignation. Its ultimate success is not measured in profits alone, but in how thoroughly it makes despair convincing.

But to be truly radical is to make hope possible. The first act of defiance against the futility economy is not a protest or a policy paper. It is the quiet, stubborn work of restoring in ourselves and our colleagues the belief that this is not all there can be. It is the choice to reject the system’s most toxic lesson: that things cannot change.

This is the task now: to unlearn the fatalism we have been taught. Because only from that place of renewed agency can we begin to build something better. In the face of engineered backwardness, the most potent medicine we have is a clear-eyed and radical hope.

Jenny Shields is a licensed clinical psychologist and nationally certified health care ethics consultant specializing in clinician burnout, moral distress, ethical trauma, and complex psychological assessments. Based in The Woodlands, Texas, she leads a private practice—Shields Psychology & Consulting, PLLC, where she offers confidential counseling, consultation, and education for physicians, nurses, therapists, and health care leaders nationwide. Dr. Shields is committed to shifting the conversation in health care from individual resilience to system-level ethical reform. She is affiliated with Oklahoma State University and regularly contributes insights through public speaking and writing, including features on Medium. Her professional presence extends to platforms like LinkedIn, Google Scholar, ResearchGate, the APA Psychologist Locator, and the National Register of Health Service Psychologists.