Sunday, September 25, 2011

"The Super Committee Faces the Challenge of Knowing the Unknowable"

From the Manhattan Institute's Medical Progress Today blog

Serious Medicine Strategy is now part of the the Manhattan Institute's Medical Progress Today Blog

Here's one of several pieces I have written for the new Manhattan Institute Medical Progress Today blog.  

Sunday, September 11, 2011

The return of fatalism: One time-tested way to save money on healthcare--embrace illness and death

Is disease a blessed event hastening our path to heaven?   Should we look beyond the pain and suffering and focus only on the end goal?  It's easy to mock this don't-worry-be-happy-just-die admonition from a 1799 religious pamphlet:

Let us learn a lesson from the seafaring man, then, and regard the bright side of even our afflictions. Instead of considering sicknesses and diseases to be only so many painful visitations, let us try to regard them, also, as so many different roads to the golden gates of heaven.

Few admit to thinking that way today, but it does seem as if, in our dismissal of science, we are strangely returning to that sort of fatalism.   Every civilization puts certain things in the ascendancy as opposed to other things: One civilization builds pyramids, another buils cathedrals, another builds grands boulevards, another builds mcmansions.  In other words, each civilization makes a series of choices: What's important? monumentalism? clericalism?  royalism?  militarism?  economic dynamism?   Another choice is science and scientific advance--either a culture celebrates, and fosters, scientific advance, or it doesn't.   And if a culture doesn't celebrate technological progress, then, in a dynamic world, it is likely to not only fail its own people, but it is also likely to be overcome by rivals. That was the story of China relative to the West from 1500 to 1945 or so, and it could be the story, in reverse, of the 21st century and beyond.    On this 9-11 anniversary, we rightly pay tribute to those who were lost ten years ago today, but surely just as important is making sure that it doesn't happen again.  And such prevention requires active measures.  Passivity and fatalism are no answer--at least not a good answer.

And yet it sure seems that for the most part, we are on an anti-science course in America today.  Yes, we have plenty of schools and institutes with "science" on their nameplate, but oftentimes, they seem at least as interested in politics, and politically correctness, as science.   And of course, while the larger culture is happy enough to get a next-generation smartphone, the larger culture also seems happy enough to assume that these wondrous mini-machines will be developed and produced by foreigners.  And of course, the climate of regulation and litigation sends an unmistakable message: anything made in the USA can be targeted by bureaucrats and trial lawyers, as politicians either cheer them on or watch passively.   

Nowhere is this adversarial culture more evident than in the area of medical R&D. As noted here at SMS, there's been a crash in Serious Medicine, which will obvious and deleterious effects on all of us, and yet the political system has been clueless.

So today we spend money financing disease and its ravages, and yet we seem uninterested in intervening to stop the disease.  Out of the $2.6 trillion that the US spends on healthcare, only around $113 billion goes for medical R&D, and that category of R&D covers everything from cancer to botox.  In other words, as a percentage of our total spend, very little is directed toward urgent national problems, such as Alzheimer's.   It wasn't always thus--for a while, we focused on polio, and we beat it.  For a while, we focused on AIDS, and we beat it back, at least in the US.    But now, we seem content just to deal with the ravages of disease.  And yet ironically, this approach isn't cheap at all, because the epidemics we confront are not the quick death of the black plague, but rather the slow disability and death that come from chronic illnesses such as Alzheimer's Disease.    So we get the worst of both worlds: no cures and we spend a fortune. 

Except maybe for a lingering few Christian Scientists and maybe some Greens, we don't do this out of a religious or quasi-religious feeling, but merely out of inertia and sloppy thinking, backed up, of course, by some quiet players who gain money and power out of the status quo.  After all, plenty of current constituencies benefit from a definition of healthcare that focuses on retroactive finance, as opposed to proactive science--think nursing homes, financiers, and non-science-minded "experts" in "public policy." 

The French critic George Bernanos argued,  “The worst, the most corrupting of lies are problems poorly stated.”  And so we see today, the problem of healthcare has been defined away from cures and defined instead as long term care.  And so the issue becomes insurance of various kinds, and not science of any kind.   So we might as well embrace the fatalism of that 18th century pamphlet. 

Hat tip: Marc Abrahams at 

Thursday, September 8, 2011

Frederic Bastiat, Call Your Office: What the Committee for a Responsible Federal Budget Would Like to See --and What Can Be Seen: Two Different Things

Under the headline, “What We Hope to See From the Super Committee,” the Committee For a Responsible Federal Budget (CRFB) weighed in yesterday with its recommendations to the Joint Select Committee on Deficit Reduction (Super Committee), which holds its first meeting on Capitol Hill on today.   The CRFB, of course, is perhaps the pre-eminent “deficit hawk” organization in Washington DC, and so its recommendations carry great weight among wonks, pundits, and, inevitably, politicians. 

But what, exactly, is it recommending?  What would CRFB have the Super Committee do?  The September 7 document outlines five sets of recommendations, mostly aimed at reinforcing the determination and credibility of the Super Committee and, by extension, Congress.   But here we will examine just one recommendation: the admonition to “Go Long,” as in, long term.  As the CRFB document puts it, the Super Committee must take entitlement spending head-on, addressing “the long-term drivers”:

Any serious fiscal plan must address the long-term drivers of our growing debt. The Super Committee must enact serious reforms to Social Security, Medicare, Medicaid, and other federal health spending.

In other words, it’s all the major entitlements that must go under the budget knife.   Okay, fair enough: Entitlements account for almost three-fifths of federal spending, and so it makes sense to look into those budget categories for savings.   The CRFB document pushes hard in this direction, advocating an overhaul of spending--including federal health spending--well beyond the familiar ten-year time horizon for federal budgeting.  Indeed, the CRFB looks ahead a full four decades, all the way to 2050: 

Based on our projections, federal health and retirement spending is slated to grow substantially, from below 10 percent of GDP today to 12 percent by 2021, 15 percent by 2035, and 17 percent by 2050.  This is due both to population aging (largely because of the retirement of the baby boom population) and to rapid health care cost growth.

Okay, so major increase in costs is foreseen.  But let’s ask ourselves: How do we really know what healthcare and retirement spending is going to be in 2050?  What do we really know about the middle of the 21st century--that is, what things will be available, and how much they will cost?   To be sure, part of the cost-increase is relatively foreseeable, because of the aging of America; the over-65 population is projected to grow almost three times faster than the overall population, and the percentage of the elderly will increase from about 12 percent of the population today to about 20 percent in 2050.   And old people, to be sure, generally cost more to treat than young people.   Moreover, for the most part, population increases and demographic shifts are relatively easy to project--although some forecasters, such as the notorious Malthusian Paul Ehrlich, author of The Population Bomb, have still managed to be grossly wrong. 

But how much do we know about the future costs of healthcare?  Answer: not much more than we know about what life will be like.   A moment’s reflection tells us that the year 2050 falls into the category of what the great free-market economist Frederic Bastiat called the “unseen,” as opposed to the “seen.”   That is, some things just aren’t knowable in advance.  And to draw upon the wisdom of another free-market economist, Friedrich Hayek, it’s a “fatal conceit”  to think that anyone can plan that far ahead.  Quick questions: What will a computer look like in 40 years?  What will the Internet look like in 40 years?  If we don’t know the answer to those questions, we don’t know what healthcare is going to cost.  To gain perspective, we might think 40 years back to telephones and early computers: How have they changed since the early 70s?  Answer: Thanks to the cost-crashing/ productivity exponentializing power of Moore’s Law, they have changed in every imaginable way, and in ways that nobody back then could have imagined.   So to the extent that computers and the Internet are now thoroughly woven into the fabric of everything we do, it’s a safe bet that computers and the Net--or whatever they will have evolved into four decades hence--will have similarly transformed and retransformed medicine in the decades to come.  And perhaps changes in healthcare will change the length of our productive worklife in some dramatic way as well.   So in other words, we have no idea what federal healthcare and retirement spending is going to be in 40 years. 

Thus a lesson straight from Bastiat and Hayek: Don’t try to predict things that can’t be predicted.  The future--to borrow the distinction made by RAND national security expert Gregory Treverton--is not a puzzle, it is a mystery.  Puzzles, of course, can ultimately be solved by piecing information together--and yet mysteries are, well, mysterious.  In this world, anyone who says he can solve a mystery by examining the pieces of a puzzle is, at best, wrong, and, at worst, dangerous. 

If we continue with our current healthcare strategy--which can be defined as decreasing amounts of new technology, plus increasing amounts of labor and financial inputs--then we will, indeed, get a costly future such as CRFB projects.    Today, for example, nearly six million Americans suffer from Alzheimer’s Disease (AD), and that number is expected to quadruple in the next four decades.  Once again, projections about the future might be suspect, but those concerning the health consequences of an aging population are easy enough to foresee, especially in the absence of any dramatic scientific intervention.  And as of today, we have no proven effective treatment for AD.  Zero.   As a result, AD care is not only labor-intensive--nursing home care for increasing armies of incapacitated dementia victims--but it also meets the definition of “futile care.”   And yet the idea of attacking the true cause of rising AD costs--as opposed to lamentations about those costs in the future--is unmentioned by CRFB.  Indeed, the idea of seeking a cure for AD is essentially ignored by the entire category of Beltway “budget experts.”  The economists and lawyers and talking-point-writers who dominate the DC debate seem oblivious to scientific transformation as an alternative budget strategy.  Three critical words vital to the self-esteem of any bureaucracy are “not invented here.”   That is, if we didn’t think of it, it can’t be worth considering.  

So we might ask: How, under the current medical-technological regime, are we going to save money on AD?   Will we simply reduce the nursing care for dementia victims?   As always, the affluent will be able to buy their way out of personal neglect--even if they have failed to buy their way out of the disease, thus demonstrating an ultimate grim equality of result.   But what about those who depend on Medicare and Medicaid?  What will happen to them?  What are the horror stories to come?   Moreover, how will those people vote?  The brave talk of inside-the-Beltway lobbying groups and legislative bodies doesn’t hold up well against popular passion expressed in the streets and at the ballot box.   That was the story of the federal government’s short-lived catastrophic health insurance program in the 80s,  of Clintoncare in the 90s, and of Obamacare in the last three years.   In other words, Members of Congress who vote for the sort of cuts that CRFB is advocating are likely to be rewarded by opinion-leaders inside the Beltway--and punished by voters outside the Beltway.   That is, elected officials can become un-elected officials and then, as a consolation prize, get a good seat at the Gridiron Dinner. 

Yet there is another path, completely ignored by CRFB, and that is the path of medical progress.  The words “medicine,” “research” and “cures” do not appear at all the in the CRFB document.   And yet it is only through medical progress that genuine medical transformation can occur.   Profound transformation is achieved by visionaries and scientists, not by financiers and bean-counters. 

It’s worked that way in the past.  Let’s take polio as an example.  Back in the early 1950s, economists calculated that the polio epidemic, then raging, would cost the US economy $100 billion a year by the year 2000 (more like $1 trillion in today’s dollars).  Yet instead of accepting the basic premise of that projection--that the polio epidemic would continue forever--we changed the basic premise.  That is, we developed the polio vaccine.   And so, instead, our expenses for polio are essentially zero.  And what’s the smart way to think about that kind of budgeting?   Going back to that projection from the 1950s, deficit hawks might have said that $100 billion a year is too much money.  So should they have said $90 billion?  Or, even hawkier, $50 billion?  The fact is, if polio were still engulfing us today, such reductions would be politically disastrous; voters would show their fury at the ballot box.  

Meanwhile, Alzheimer’s today is costing the US economy $172 billion a year, according to the Alzheimer’s Association.    And the cumulative cost is headed up to $20 trillion by 2050.   Deficit hawks might say those dollar figures should be reduced by 10, 20, maybe even 50 percent or more; that’s what deficit hawks do.      But there’s still that nagging issue of “how?”  As we have seen, AD care is expensive; indeed, labor-intensive healthcare runs into the iron logic of Baumol’s Law--if it’s labor-intensive, it will be expensive.   In other words, it’s one thing to declare that eldercare should be X-percent cheaper in the future, it’s another thing to achieve those savings.    As the news from the UK reminds us, the obvious solution is rationing--rationing that costs lives.   And from rationing, it’s not hard to get to even more draconian cost-saving solutions.   As always, it’s easier to envision these solutions inside a marble palace of planning, as opposed to at an actual patient’s  bedside.

Interestingly, CRFB seems to have grappled with this issue--the issue that its proffered solution is unpopular with the American people; the polls, after all, show that by 3:1 or 4:1 margins, people don’t want to see cuts in Medicare.   So perhaps in anticipation of a likely political backlash, CRFB is telling the Super Committee that it’s okay to “backload” the cuts--that is, have them come beyond the ten-year time horizon.   Super Committee members are told, in other words, that it’s okay to make negligible cuts in the near term, as long as big cuts are made in the long term:  

To reassure markets and put our budget on a sustainable path over the long-term, the Super Committee must therefore address the growth of the nation's largest entitlement programs, and give priority to those reforms with the potential to slow long-term growth paths (even if they do not have significant scoreable savings this decade). Reforms to Social Security, Medicare, and Medicaid are central to improving the long-term imbalances. [underlining in original]

Okay, so in other words, the CRFB is telling the Super Committee that it’s all right to make small cuts in the near term, over the next decade, as long as the big cuts come later.   But we might ask: Isn’t that the essence of kicking the can down the road--that is, telling Super Committee members, and Congress as a whole, that the big cuts need come only many elections hence, in 2021 or thereafter?   And what economic problem does that solve?  Aren’t we in a crisis now? 

What could be the reason for this budget-fudging?   One possibility is that CRFB accepts the Keynesian argument that immediate cuts in spending--and thus in consumer demand--might damage the economy.  Another possibility is that entitlement cuts in the near term are just too painful politically; that is, if such cuts are on the menu where the voters can see them, the whole project collapses as the politicians flee.   

Yet we might ask: If the work of CRFB is not about cuts anytime soon, then what is it about, exactly?   A third possible explanation is that the CRFB simply wants a deal.  That is to say, CRFB wants something that it can call a success.  Or, to be even more cynical about it, with apologies to the late Sen. George Aiken, it wants something that can be dubbed a “victory,” no matter how transparently risible that “victory” might be.   That is, something that proves that the American Establishment can still do something--anything.   Establishmentarians always like to emphasize their credibility, their seeming competency.  And the CRFB is the epitome of an operationally conservative establishment--not ideologically right-wing, just eager to tamp things back down to something that looks like normalcy.  

So back to CRFB’s  recommendations to the Super Committee.   And if those numbers are built on bad assumptions?  Well, that’s a problem to addressed at some later time.  The important thing, it seems, is that we have a deal in our time.  

The problem for the rest of us, though, is that the problems we face are not normal--and neither are the solutions.  Science, and scientific progress, are inherently disruptive, and if the political Establishment can’t handle that truth, well then, we need a better Establishment.  Indeed, for reasons that C. P. Snow outlined a half-century ago, contemporary political and cultural can barely handle science and what it brings.  And so the establishment just pretends that science doesn’t exist.  But as Galileo said under his breath at the Inquisition, eppur si muove.   That is, just because the reigning orthodoxy says that something isn’t happening, that doesn’t mean it isn’t happening.   As they say, if we don’t deal in reality, other people will.   Reality is a stubborn thing.  Indeed, the only way that the Establishment can possibly makes it straight-line projections  work is by squashing science--and we know how that ends.   

Then and now, politics, and the desire for orthodoxy, has trumped looming reality.   The obvious reality is that if we don’t do something radical about AD and other costly diseases, none of these budget deals are going to be work out as the American people might hope.  Either we will vastly more than the “deficit hawks” wish, or we will move toward rationing--or worse.

Today we see huge edifices of political thought being based on projections about the budget deficit in 2021, 2050, or even later.   There’s nothing wrong with predicting the future--so long as there’s an adequate amount of humility in the predictions.  But the bold predictions of CRFB as to what will happen in the middle of this century are based on a kind of know-nothing hubris.  The hubris that pretends to knowledge about what is unseen and mysterious.   And that is, indeed, a fatal conceit.  

Governor Rick Perry takes on cancer at the Reagan Library presidential debate

From the Politico/NBC Republican presidential debate last night: 

PERRY: But here's the facts of that issue. There was an opt-out in that piece of -- it wasn't legislation. It was an executive order.

I hate cancer. We passed a $3 billion cancer initiative that same legislative session of which we're trying to find over the next 10 years cures to cancers. Cervical cancer is caused by HPV. We wanted to bring that to the attention of these thousands of -- of -- of -- tens of thousands of young people in our state. We allowed for an opt-out.

I don't know what's more strong for parental rights than having that opt-out. There's a long list of diseases that cost our state and cost our country. It was on that list.

Now, did we handle it right? Should we have talked to the legislature first before we did it? Probably so. But at the end of the day, I will always err on the side of saving lives.

Rick Perry was responding to questions about his controversial 2007 executive order to vaccinate girls in Texas with Gardasil, as a way of warding off the human papilloma virus that can cause cervical cancer.   Obviously anything to do with sex--especially teen- and pre-teen sex--gets into touchy issues of family and family values and parental rights, but equally obviously, vaccinations as a whole are a good idea.   Think polio vaccine, for example, or, in an earlier era, the smallpox vaccine.   Perry has since expressed regret for the way that the Gardasil issue was handled, but the larger story of how Texas is fighting cancer is quite interesting--and quite compelling.    

And fighting cancer in Texas--or anywhere--isn't just a good thing for compassionate health reasons, it's also a way to job-creator.  The Texas Medical Center in Houston, for example, employs 61,000 people.  Statewide, and nationwide, medicine is a much bigger industry--one of the most dynamic industries we have. 

Tuesday, September 6, 2011

What Happens When “The doctor will see you now” Is Replaced by “Show me the money”?

A fascinating article appeared in Monday’s New York Times, headlined, “Adjusting, More M.D.’s Add M.B.A.”  That is, medical doctors are now getting master’s degrees in business administration.  As the Times explains:

As recently as the late 1990s, there were only five or six joint M.D./M.B.A degree programs at the nation’s universities, said Dr. Maria Y. Chandler, a pediatrician with an M.B.A. who is an associate clinical professor in the medical and business schools at the University of California, Irvine. “Now there are 65,” she said.

Mark V. Pauly, a longtime leader of the health care management program at the Wharton School at the University of Pennsylvania, said, “A light bulb went off and they realize that health care is a business.”

And so doctors are learning business as well.   As Penn’s Mark Pauly says in the Times article, “healthcare is a business.”   That point is worth pausing over: doctors as a business.  Some cynics will say that this is nothing new, that doctors have always been in it for themselves, but as the Times story makes clear, this is indeed a new businesslike trend in the offing.  So how to regard this trend?  What does it mean for doctors--and for the rest of us?  

On the one hand, it’s hard to blame doctors for shifting toward a greater focus on businesslike profit-maximization.  Why?  Because while doctors are admired by the general public, they are not respected by powerful blocs in society.   A 2010 Gallup poll shows that health professionals (nurses, pharmacists, and doctors, but hereafter, for simplicity’s sake, we’ll just “doctors”) finish at or near the top in rankings by the public of most admired professions.  Yet at the same time, doctors are very much disrespected by big financial players in society, including lawyers, insurance companies, and governments.   And so doctors must compare the specific negative power of those antagonistic blocs against the general esteem of the public--and today, the power blocs have an edge over the public.  That is, the real muscle in our society belongs to lawyers bent on suing doctors, also suing medical drug- and device companies.   And other segments of society, including insurance companies and governments at all levels, are seemingly guided by a sole objective: to control and cut costs, no matter what the other consequences might be.   In such an environment, perhaps it makes sense for doctors to muscle-up financially in self-defense.  Okay, so that’s why doctors are getting MBAs.

But on the other hand, what about the rest of us and our health?   What about the public interest? Yes, it’s a free country, but are we as patients better off if doctors take time away from medicine to focus on business?   That is, if doctors become so focused on making money that they take two years to get a formal MBA?   And more importantly: If doctors become doctor-businesspersons, is that really good for our national health?   Might we better off, instead, if we could think of ways to incentivize doctors to put more energy into medicine and the healing arts?  

One thing is sure: If the doctor-business melding trend continues, big things in our society will change.  First of all, it means an inevitable downshift in the public esteem of doctors.   One ultimate source of medical prestige is the feeling that doctors are motivated by at least a modicum of altruism.  It’s at least a little bit of altruism, people think, that inspires doctors to put themselves through the rigors of strenuous education in order to help others live better and longer.  The public realizes, however vaguely, that the Hippocratic Oath, composed some 2500 years ago, is still the guiding medical-ethical document for the profession.  The modern American version, for example, includes these idealistic lines:

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

Obviously not all doctors have lived up to these high standards, but just as obviously, most doctors have--that’s why doctors are so respected.  Moreover, the reality that the medical profession, plus medicine, has done great good is undeniable; over the last two centuries in the US, for instance, life expectancy has more than doubled, while the infant mortality rate has plummeted by some 98 percent.

Yet what might happen if doctors just became another species of businessmen?  What happens if the Hippocratic Oath is supplanted by profit-and-loss statements?

One early clue comes from those same Gallup rankings, which showed that the honesty and ethics of doctors are rated “very high/high” by 66 percent of the population, while business executives are so rated by just 15 percent.   So if doctors turn into just another category of businesspeople, it’s logical to assume that their prestige will drift down toward the general level of businesspeople.  

More urgently for most of us, what’s the health impact of purely businesslike doctors?   What happens when you go to such a doctor?   Will he or she want what’s best for you, the patient?  Or what’s best for his/her bottom line?   There’s a big difference.  As noted, the Hippocratic Oath stipulates, “I will prevent disease whenever I can, for prevention is preferable to cure.”   But of course, from a doctor’s point of view, cure, or attempted cure, is a better financial bet than prevention.  From a purely financial utilitarian point of view, separated from any ethical framework, it makes perfect sense not to tell a fair-skinned patient about the danger of too much sun--and then treat the patient, a few years or decades later, for skin cancer. 

Once again, despite the Hippocratic Oath and all the other medical canons, we have seen plenty of profiteering doctors who eagerly order unnecessary and duplicative tests and even superfluous operations.   Still, so far at least, we can say that these are rotten apples in the professional barrel.  Yet what will happen if and when medicine becomes fully “incorporated” and the new goal for doctors becomes hitting revenue targets?   If this were to happen, the most obvious consequence is that the prestige of the medical profession would plummet.

Some doctors, to be sure, might say, “Fine.  Keep your prestige.  We’ll take the money.”  Yet meanwhile, for every doctor who reaps the monetary benefit of an MBA, there are another hundred doctors who have been proletarianized--that is, turned into an overworked and underpaid wage-slaves--by Medicare or the insurance companies.  That is, proletarianized doctors are put to work on the medical equivalent of an assembly line, told what to do by a bureaucracy, told what to prescribe and how fast to do it.  Yet either way--whether doctors learn how to make more money as corporate operators or just accept becoming salaried employees of a public or private bureaucracy--the uniqueness of their profession will be lost.  And that will be a huge loss to the commonweal.   

Once again, those words: “healthcare is a business.”  As a matter of national policy, is this really what we want?   Do we want to eliminate the elevating aura of professionalism and move to total bottom-line-ism? 

We might learn the fate that doctors could face from the precedent of lawyers.  Once upon a time, lawyers were seen as a self-regulating guild, in which private appetites were subordinated to what we would now would call “the public interest.”  In England, mother country of American law, new barristers would be “called to the bar” and then spend their careers as members of an “inn of court,” which were a combination of insider’s club, workplace, and classroom for continuing legal education.   The guiding idea was that senior barristers would oversee the proper development of the legal profession, providing discipline and sanction as needed.  And such supervision was indeed needed, because after all, lawyers have extraordinary power--most obviously, the power to make or break individuals and firms with lawsuits.  And so the masters of the bar prohibited, for example, champerty--over-zealous or manipulative lawyering.  Were these long-ago lawyers motivated by idealism?  Not necessarily; they might have made the practical calculation that if they didn’t police their own profession, others would do it for them.

In the US, bar associations attempted to fulfill the same policing and oversight function.  And so, for example, the American Bar Association forbade lawyers from advertising, beyond the use of business cards. 

Those rules were overturned in the 1970s on free-speech grounds, in keeping with a larger sense that the US economy needed to be deregulated.  Critics of the old system were right to criticize it as cliquish and self-protecting, but they were wrong to think that the new wide-open system would be an improvement.  Today, the legal profession has been entrepreneurialized; one consequence has been the rise of John Edwards-type legal buccaneers--lawyers becoming millionaires and even billionaires.   Are we really better off being a nation of all lawsuits, all the time?   Americans curious as to the cumulative harmful impact of this litigation might take a look at Walter Olson’s website,

Another ill consequence to our healthcome to our health in the form of those ubiquitous television spots, trolling for clients, featuring phone numbers such as 1-800-BAD DRUG.   In other words, legal predators are now free actively to seek plaintiffs to sue medical providers for any and everything.   So now we see what happens when a profession is fully and totally commercialized, even as it maintains its coercive power; now, more than ever, the power to sue is the power to destroy.   In today’s legal environment,  ethical canons and traditions of restraint have melted away in the white heat of publicity- and profit-seeking litigation.   The cost to doctors is bad enough, in terms of malpractice insurance, but the cost to patients has been infinitely greater, in terms of damage done to medical research and development.   As noted at in the past, the real story of the past two decades has been the precipitous decline in the number of new drugs and medical devices coming to market, as well as the wipeout of the medical venture-capital sector.   

So over the last few decades, lawyers have been de-regulated and de-professionalized, and the result is that the profession has been enriched, even as its ethical prestige has been degraded.   So now we could go further and ask: What would happen if other professions were similarly de-professionalized and profit-maximized?  What would happen to the police?  Or to the military?  Or to the courts?   To be sure, there are libertarian theorists who think such privatization would be a great idea, but mercifully, not too many Americans agree with them.  

For most of us, it makes sense to see our society as a series of sectors, each with its own sectoral  rules, under the overall umbrella of the Constitution.  Public officials are supposed to operate according to one set of rules.  So are the clergy.  And families, too, have some unique rights.  This is the essence of pluralism, and it is also the essence of common sense.   Edmund Burke called these different groups “little platoons,” while Peter Berger and Richard John Neuhaus called them “mediating structures.”  It’s impossible to imagine society functioning without these legal and traditional privileges.   

Yet at the same time, untrammeled market forces, unmodified by the morality or ethics of non-market entities, are a threat to each of these little platoons and mediating structures.   And that’s why we should worry about what is happening to the medical profession--what doctors are doing to themselves, and what they would, in turn, do to us.  

In recent decades, we can note, advocates of pure market forces have gained ascendancy in business thinking.  One oft-heard argument is that the greatest goal of a corporation should be to maximize “shareholder value,” and therefore all other corporate goals should be subordinated to that prime objective.   And so, for example, the interests of corporate stakeholders, as opposed to shareholders, are given short shrift as a matter of policy and ideology.  Such a view may have its place for a company making widgets, but if the same value-system migrates into a medical office, trouble will ensue.   

It’s not hard, for example, to foretell that corporatized doctors, schooled in the new verities of corporate methods, will see the Hippocratic Oath as less and less of a hindrance to their pursuit of profit thorough any possible avenue.    And so just as “innovative” financing schemes became the bane of the financial markets in recent years, so new-style doctors could find “innovative” ways to extract money  not only out of patients, but also out of society.   Organ sales from willing donors--or unwilling donors?   Any number of Coma-like scenarios?   So then we will get the worst of both worlds: greedy doctors who do a bad job for patients, while costing the individual and the country even more more money. 

Some will say, of course, that there’s no alternative, no turning back.  The forces of modernity--from global competition to the Internet to the rising health consciousness of the citizenry--are shaking up the medical profession.  And so we must go forward, we are told, into the further  transformation of the medical profession.   

It is indeed true that we can’t go home again to the idea of a country doctor.    But we don’t have to give up on the traditional mores of medicine.  We can keep the best of our sacred medical tradition and yet also reap the best of what science has to offer.  How?  We will explore that in the next installment.