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The Inevitable Depersonalization of Medicine

March 22, 2010

The WSJ re-posted an excerpt from Milton Friedman’s original article “A Way Out of Soviet-Style Health Care” a few days before the passage of the behemoth bill now known as ObamaCare. The mentality behind the legislation, of course, is hardly novel; attempts to insulate people from the costs of health care have been infecting public policy debates for as long as politicians have been deciding “public” policy. In Friedman’s piece, he quotes from the novel by Alexander Solzhenitsyn to demonstrate a vision of the consensual relation between the patient and the physician.

It is this freedom of association, the right to choose with whom one will exchange that is at the heart of matter of healthcare “reform”, yet this principle is conspicuously absent from the public discussion. Friedman follows this fictional scenario with an historical account of how the healthcare industry (and the nature of the relationship between provider and receiver of services) has been transformed over the years by political manipulation to become the distorted private/public healthcare system that is today condemned on both ends of the political spectrum.

In the words of Dr. Oreschenkov in conversation with Lyudmila Afanasyevna, a longtime patient and herself a physician in the cancer ward: “In general, the family doctor is the most comforting figure in our lives. But he has been cut down and foreshortened. . . . Sometimes it’s easier to find a wife than to find a doctor nowadays who is prepared to give you as much time as you need and understands you completely, all of you.”

Lyudmila Afanasyevna: “All right, but how many of these family doctors would be needed? They just can’t be fitted into our system of universal, free, public health services.”
Dr. Oreschenkov: “Universal and public—yes, they could. Free, no.”

Lyudmila Afanasyevna: “But the fact that it is free is our greatest achievement.”

Dr. Oreschenkov: “Is it such a great achievement? What do you mean by ‘free’? The doctors don’t work without pay. It’s just that the patient doesn’t pay them, they’re paid out of the public budget. The public budget comes from these same patients. Treatment isn’t free, it’s just depersonalized. If the cost of it were left with the patient, he’d turn the ten rubles over and over in his hands. But when he really needed help he’d come to the doctor five times over…

“Is it better the way it is now? You’d pay anything for careful and sympathetic attention from the doctor, but everywhere there’s a schedule, a quota the doctors have to meet; next! . . . And what do patients come for? For a certificate to be absent from work, for sick leave, for certification for invalids’ pensions: and the doctor’s job is to catch the frauds. Doctor and patient as enemies—is that medicine?”

“Depersonalized,” “doctor and patient as enemies”—those are the key phrases in the growing body of complaints about health maintenance organizations and other forms of managed care. In many managed care situations, the patient no longer regards the physician who serves him as “his” or “her” physician responsible primarily to the patient; and the physician no longer regards himself as primarily responsible to the patient. His first responsibility is to the managed care entity that hires him. He is not engaged in the kind of private medical practice that Dr. Oreschenkov valued so highly.

When the talking heads decry the “death panels”, “rationing” and “lack of choice” they fear will come from this bill, their argument would be better served by acknowledging the fundamental principle of free exchange that has been methodically eliminated from the healthcare debate. Such freedom results in a infinite number of possible outcomes in each transaction between provider and consumer. The purveyors of socialist thought, however, keen to win favor (and thus democratic political power) with the masses, have sought to equalize those outcomes through their long quest for “universal” healthcare.

As economic freedom is still widely valued (at least in spirit), healthcare has been necessarily painted as a “special case”, where the normal rules (and outcomes) of free exchange ought not apply. Just like a “gravity-free” zone, enacted by political decree and enforced by police action would be an obvious farce in the middle of an airport, the idea that a doctor-patient relationship could possibly be more effective and efficient absent the freedom of both parties to set their own terms is laughable. The consequences of ignoring principles are unavoidable, but the economic illusionists seeking nirvana in price controls and regulations are apparently as happy to live in denial of those consequences as they are to preach their gospel to the willing participants who make their rational denial possible.

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