Some people worry themselves sick that you might not do the right thing for
your own health.
"Consumers are simply not equipped to manage their own care...." according
to Michael E. Porter, Ph.D., and Elizabeth Teisberg, Ph.D., writing in
"JAMA," the journal of the American Medical Association this March according
to Jane Orient, MD, editor of "AAPS News" in her article "Is
Consumer-Directed Care Safe?" in this month's newsletter.
Grace-Marie Turner, president of the Galen Institute, often asks audiences
"Do you think you are incapable of making decisions about your health? Raise
your hands please." Nobody ever raises a hand. As Turner said in an
interview posted on her institute's website "Many politicians simply don't
believe individuals can make decisions about their own health care. They
believe it's too complicated, and it needs to be centralized. They want to
assert their paternalistic benevolence."
Many doctors concerned about their patients' well-being are appropriately
concerned when a patient doesn't follow an agreed-upon treatment plan; we
often label such a patient "non-compliant." One patient informed the doctor
"there are some things more important than health." The doctor was so
surprised that she wrote a letter to the New England Journal of Medicine
describing this unsettling experience. This patient simply didn't agree with
the doctor's underlying assumption that good health is the highest good.
Some doctors assume the role of the patient's central controller. For
maximal patient benefit, the doctor should indeed be an expert advisor but
the patient must participate in the decisions.
Politicians often have interests different from the citizens; as a result,
politicians often devote resources to things not considered priorities by
the supposed beneficiaries. Paul Starr is a Princeton University Professor
and author of the book "The Social Transformation of American Medicine." In
the book, he writes, "Political leaders since Bismarck seeking to strengthen
the state or to advance their own or their party's interests have used
insurance against the costs of sickness as a means of turning benevolence to
power."
In medical care, it's bad enough. Elite central planners create ongoing
disasters in many other human activities, such as foreign aid for the poor
in underdeveloped countries.
Marvin Olasky, professor of journalism at The University of Texas at Austin,
shows "How Bad Advice Hurts Poor People" in his article "Planners vs
Searcher" published this February by the Capital Research Center. (See
http://www.capitalresearch.org/pubs/pubs.asp?ID=553 and
http://www.capitalresearch.org/pubs/pdf/CC0207.pdf once the website
upgrading is complete, by about June 20).
Olasky quotes William Easterly's new book "The White Man's Burden,"
contrasting Planners and Searchers: "A Planner thinks he already knows the
answers; he thinks of poverty as a technical engineering problem that his
answers will solve. A Searcher admits he doesn't know the answers in
advance; he believes that poverty is a complicated tangle of political,
social, historical, institutional, and technological factors."
The different assumptions of planners and searchers lead to different
approaches. "Planners apply global blueprints; Searchers adapt to local
conditions.... A searcher hopes to find answers to individual problems only
by trial and error experimentation. A Planner believes outsiders know enough
to impose solutions. A Searcher believes only insiders have enough knowledge
to find solutions, and that most solutions must be homegrown."
Utopian socialist planner Robert Owen wrote that permanent peace and harmony
could "be accomplished... with far less difficulty and in less time than
will be imagined" way back in 1857.
This is eerily similar to (though much more succinct than) JAMA editors
recently writing "Given the magnitude and complexity of the problem of
ensuring access to health care and the need for comprehensive health system
reform, it is clear that patchwork, short-term, and seemingly popular
approaches will be insufficient to achieve the type of definitive,
meaningful, and financially viable reform that is necessary...." Despite
centuries of experience, these doctors still believe that some central
authority could magically enact "definitive... reform."
"Central governments hate the idea that someone out there is taking care of
business without their help" as Charles Murray wrote 15 years ago in
describing his personal experience living and working as a young Peace Corps
volunteer in Thailand. "The question is, which is better for the people
involved?" referring to "the most fundamental sources of human
satisfaction." "The underlying meaning of 'earning a living' - earning one's
life - is at the heart of human happiness."
Murray also saw "how easily a well-meaning outside agency can destroy the
fragile organism that is a functioning community."
I believe the same is very often true in the medical community.
Every new medical program or initiative initially requires a lot of time and
resources, which must be taken from other medical work. As with many other
innovations, the value added must be high enough to compensate for the value
taken from other work.
For example, emergency room nurses spend about half their time doing
paperwork to fulfill a large variety of goals and requirements, including
patient safety. That's a lot of time not spent actually taking care of
patients. Yet it's almost heretical to suggest that less may result in more,
in this case, that less time spent on paperwork might result in more time
spent achieving better medical results.
Obviously, the best way to analyze medical innovations, whether in surgery,
patient safety or other medical activity, is to try new ideas out very
carefully and on a limited scale. Anesthesiologists' safety ideas were
tested and proven locally before becoming standard practice across the
country.
Central, federal government laws based on the latest bright medical or
policy idea reduce everyone to the level of a guinea pig or lab rat. Once
everyone in the country is in the experiment, there's no one outside the
experiment for comparison. This is very unscientific but very popular
politically.
This parallels the news media expecting every presidential candidate to have
a Total Solution for medical care.
"The right plan is to have no plan" imposed by foreign outsiders, according
to Easterly.
I would say the same for most of the big policy ideas promoted by the
federal government. Individuals should be free to look to medical,
financial, educational and other experts of their own choosing; they should
not be required to accept government-provided caseworkers for the vast
majority of their needs.
This is certainly true for individual medical patients, whose own personal
interests must take priority over the interests of the doctor, hospital
staff, and government bureaucrats.
Editor's Note: Robert J. Cihak wrote this week's column.
