Emerald Group Publishing Limited
Copyright © 2004, Emerald Group Publishing Limited
The limits of “Choice”
The limits of “Choice”
Keywords: Economic models, Strategic choices
Abstract It has become fashionable in recent years to assume that the “business model” of a contractual relationship between provider and consumer, can be replicated in all areas of social life, including the provision of public services. This notion arises partly as an understandable reaction against uniform and unresponsive forms of state provision. However, this reaction turns quickly into a dogma that all state provision is inherently sclerotic and that the “market mechanism” inevitably produces better results. Market fundamentalism is as determinist and as limited in its outlook, as the most doctrinaire variants of Marxism. Both reduce all areas of life to economic relationships and so commodify human relationships. Market fundamentalism's favourite mantra is “choice”, but in an area like medicine, this is a chimera. The doctor-patient relationship, and the wider relationship between medicine and society, depends on trust, reason and on ethos of public service. These qualities are being eroded by both “progressive” dogmas and neo-liberal economics.
Patients should be free to choose their doctors, of course, but this does not mean that patients are customers in the ordinary sense of the word. The relationship of doctor to patient is not a purely commercial one, even where the patient pays the doctor directly in cash for his services, as he leaves the consulting room. George Bernard Shaw, as always more interested in appearing clever and witty than in the truth, famously said that if you paid a surgeon to cut off your leg, he would cut off your leg. In fact, this was never the case, except for the odd unscrupulous villain, which every profession of substantial numbers does and must contain because human nature decrees it; and while the patient (assuming he is not affected by mental disability) has the right to refuse any treatment that the doctor prescribes, the doctor has the duty to refuse the patient what he wants if he considers that it is bad for him, however much the patient may be willing to pay for it.
A patient cannot, therefore, go to the doctor and say, “I'll have one amputation, a bypass graft and two doses of electro-convulsive therapy,” as if he were in a grocery store, choosing items for his dinner. Unlike the confectioner, the doctor has an inescapable duty to decide whether what the patient wants is good for him.
What prevents the doctor from doing merely what the patient wants, even when he is paid directly by him, and even if the patient threatens to go elsewhere to get what he wants? It is a system of professional ethics that has grown up historically, over centuries. The doctor acts in the patient's interests, as he sees them, not according to the patient's wishes, though of course he also considers the latter. The doctor is, or should be, the patient's advisor, not his butcher or baker (to use the tradesmen adumbrated by Adam Smith), nor is he even his friend. In the relationship between the doctor and patient, a considerable element of benevolent paternalism does, or should, enter: after all, the doctor is (typically, though not in every last case) in a position of superior knowledge and experience vis-à-vis his patient. That is why the patient goes to him.
In other words, even in an avowedly private system of medical care, considerations other than purely financial ones enter the doctor-patient relationship.
Moreover, under any conceivable system, we should expect cardiac surgeons, chest physicians and others to be properly trained and certified. We do not expect to find out the hard way that the man to whom we have entrusted our heart or our kidneys is, in fact, a charlatan with no claim to expertise. Hardly anyone would wish to have a completely unregulated medical market, in which anyone could claim to be anything, and in which the only guarantee of reasonable practice would be after-the-fact tort law. Such a market existed (except for the tort law element) in the 18th Century, when university-trained physicians knew no more of practical value, and possibly rather less, than wise-women.
But it is hardly possible to revive now, and while there is still a comparatively unregulated market in the so-called complementary medicine, this market is highly parasitic or at least dependent upon the existence of the regulated, official market. Alternative practitioners treat principally those patients who either have little wrong with them, or whose chronic condition has been diagnosed by a regular physician, and is untreatable, or not satisfactorily treatable, by conventional means. No one injured in a car crash, after all, goes to an iridologist.
The idea, therefore, that in medical practice market relations are good and regulation is bad is both crude and untrue. Moreover, almost no one believes it, in the sense of holding the view consistently. The question is not one of market vs regulation, as if the two grand principles were involved in a boxing match, a fight to the finish, in which one or other must be the winner and the other the loser. The matter is more one of getting the right balance, of reaching an equilibrium, that will no doubt always be unstable but which will serve the interests of the patients as well as possible at any given moment.
There is not only the question of regulation per se, but of who will regulate and how: whether, for example, it is best done by the government or by the profession itself, or some other body. As for market relations, hostility to them in their entirety is just as foolish as hostility to all regulation. To say, with Bernard Shaw, that to give a man a pecuniary interest in performing an operation is madness, is to forget that to give a man no pecuniary interest in his work is to deprive him of what all experience has taught is the greatest and most effective of human motives, at least once the division of labour has occurred. The market is like nature: though you drive it out with a pitchfork, yet it will return.
So it is not to belittle commercial relations to say that more than such relations are necessarily involved in the transaction between doctor and patient, any more than it is to belittle regulation to say that services tend to be better when money changes hands and there is competition between providers of services. This may all seem perfectly obvious, but it is frequently forgotten or even denied.
The doctor's professional ethics are maintained partly by coercion and fear – if he does not comply with the rules laid down he will eventually lose his livelihood – but also by an esprit de corps and a sense of duty to his patients and even to humanity. This is the kind of idea that is hated with equal hatred by market fundamentalists and by Leninists, who in a sense agree on one thing: that where market relations exist, they are the only relations that exist. The difference between them is that while the market fundamentalists believe that this exclusivity is good, and ought to be encouraged or rather given into, the Leninists believe it is bad and ought to be suppressed, if necessary by wholesale slaughter.
Esprit de corps, though, is a delicate plant, and is easily destroyed, or at least reduced. The destruction of non-profit making institutions (of the kind that surely will always be necessary) on the grounds of economy has a profound effect upon such esprit. Administrators in search of supposed value for money close down such institutions without realising fully what they are doing. Let us leave aside the question of whether the administrators are in fact capable of deciding whether institutions represent value for money in so precise a fashion that closing them precipitately is a sensible manner of proceeding: though the answer is clearly no. Let us just consider what the closure of a hospital may mean for those who have worked in it for many years. Many, in fact, will have devoted the best years of their lives to building up their department, in which they may well take a great pride. Over the years, they will also have developed many informal relationships that smooth the working of the system (and some, no doubt, that have the opposite effect). Then, at the stroke of a pen, and on the basis of a few calculations of doubtful validity, which in practice are almost always erroneous, a decision is taken by functionaries of lowish calibre and no loyalty (they seem always to move to other jobs after they have taken their largest irreversible decisions, so that they can never be held responsible for them) to destroy the work of many lifetimes.
I am not considering this from the point of view of the personal distress of the people whose work is thus destroyed: rather, I am considering it from the point of view of esprit de corps and loyalty to institutions as such. So long as there are intangible rewards, as in professions such as medicine there ought to be, things like esprit de corps and loyalty to institutions matter, though it is difficult to quantify how much. Only a man with the soul of an accountant, however, who believed that double-entry book keeping captured the whole of human reality, would doubt it.
The demonstration effect of closing down institutions at the drop of a spurious calculation is very considerable. Why devote yourself to an institution, why build anything up, why do anything that your contract does not strictly require of you, if some passing bureaucratic ship in the night can undo everything you have done over decades, in the matter of a few days? The unbridled search for value for money leads directly to a loss of value for money.
Take the question of institutional tradition. Many old hospitals had grand portraits of former senior staff in their corridors and expensively furnished common rooms, with lists of such staff painted in gold upon boards. The people who did this knew what they were about: much better than the philistines of the later 20th Century, whose understanding of what makes people tick is so much cruder and less sophisticated than that of their forebears.
Theodore DalrympleCo The Spectator, 56 Doughty Street, London WC IN 2LL