Most of us believe we are parties to a social contract, not a business contract. We are not vendors, and we are not merely free economic agents in a free market.

Arnold S. Relman, M.D.

That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. But that is precisely what we have done. And the more appalling the mutilation, the more the mutilator is paid.

George Bernard Shaw

The health-care "revolution" that was the centerpiece of the Clinton administration's "politics of hope" has fizzled into a tinker. And it's a tinker that many sensible people believe will actually make things worse. There is no shortage of blame for the failure of the revolution. Partisan politics has turned every issue faced by the administration into a major distraction from the health-care agenda. Pressure from lobbyists has been unrelenting. And the proposal that finally issued forth from the administration, after months of work behind closed doors, was long, complex, almost incomprehensible, and easily susceptible to murder by sound bite.

And so it has been murdered. But in truth, I think it was a mercy killing. The Clinton proposal was doomed from the start. Even if it had passed intact, it wouldn't have worked, because it failed to address the most fundamental problem with modern medical care in the United States. That problem is that medicine, once a calling of high moral purpose, is now just a lucrative career; that medicine, once a valuable public service, is now an "industry." Any "revolution" that simply accepts this change in the character of medical practice and then tries to fiddle with incentives to keep costs down and serve more people will merely perpetuate our current ills.

Clinton's "managed competition" proposal, and all the competing plans that are described by their adherents as more moderate, are concerned with finding ways to reform and regulate the business of health care. What is really needed is much more extreme--a proposal that eliminates health care as a business. For this transformation to occur, we need a structure for providing medical services that takes health care off the market--some sort of national health insurance. And beyond that, we need patience. Just as it took a generation or so of socialization for medical professionals to be turned from caregivers into businesspeople, it will take a generation or so of socialization for the process to reverse. I think the Clintons--both Bill and Hillary--know this; it's pervasive in their rhetoric. But the gap between their rhetoric and their proposal is huge. The rhetoric is full of moral exhortation, but the market-based proposal virtually guarantees that the exhortation will fall on deaf ears.

What's wrong with health care as a business? Well, just imagine having the same attitude toward your doctor that you have toward used-car salesmen: "They're out to get us. They'll stop at nothing. We better defend ourselves." In the world of commerce, we expect, and guard against, the worst. Not so in the world of medicine, and in the professions more generally. "Profession" was originally used in a specifically religious sense, to describe the act of taking vows to consecrate oneself to religious service. Central to the notion of profession was the idea that the work of the professional was valuable, was in a sense holy work. In modern usage, the word has retained some of its moral tone, along with the notion that professionals are governed by objectives and standards that demand rigorous training, honesty, integrity, and commitment to excellence.

For almost everyone, medicine is what comes to mind as the best and clearest example of a profession. The practice of medicine requires extensive training, highly specialized knowledge, and continuing education. Doctors perform an incredibly valuable public service. They save lives, ease suffering, prevent disease, and help bring new life into the world. The performance of doctors is held up to very high technical standards, standards that are developed and enforced by professional organizations. And their performance must meet high ethical standards as well. For example, the International Code of the World Medical Organization states that, "a doctor must practice his profession uninfluenced by motives of profit." And the American Medical Association (AMA) has a set of ethical principles meant to govern the conduct of all doctors that includes the following:

* Doctors should show compassion and respect for human dignity.

* Doctors should deal with patients and colleagues honestly.

* Doctors should expose incompetence or dishonesty in their colleagues.

* Doctors should continue to study, and to make relevant information available to patients and to colleagues.

* Doctors should recognize a responsibility to participate in activities that contribute to improving the community.

Because doctors provide such a valuable service and have such high standards, we respect them. And it is largely because medicine is a profession with high standards and commitment to public service that so many talented young people choose to enter it. Because of their commitments to service and excellence, we don't begrudge doctors the opportunity they have to earn substantial incomes, for we believe that it's the service, and not the income, that draws them to their profession.

It's a very good thing that medicine is a profession with high technical and ethical standards, for almost none of us who rely on medical professionals have the expertise to evaluate them. Aside from occasional crude but dramatic evidence of success or failure (does the patient live or die?), we patients are at a loss when it comes to judging how well we are being cared for. We have little alternative but to trust in the integrity of the doctor, as well as in the institution that does the training and the organization that sets the professional standards. Trust--not only in a person's skill, but in his or her character--is absolutely essential.

Such trust is warranted so long as doctors and their professional organizations have as their principal mission the assurance of quality service to patients. But, of course, doctors and their organizations have another mission. In addition to seeing that society is well served by their profession, they try to assure that their profession is well served by society. So for doctors and their professional organizations to serve the public good, they must maintain an appropriate balance between serving the public and serving themselves.

A challenge to maintaining this balance is posed by the fact that at the same time that the professionalization of medicine created people of skill and dedication and certified them, it had another effect. It set itself up as a kind of gatekeeper, regulating public access to the profession and its products and services. At the same time that state licensing requirements assured a certain standard of expertise, they gave the medical profession the power to determine who became a doctor and how many doctors there would be. At the same time that the use of prescriptions regulated the distribution and use of powerful drugs, it determined that even the treatment of the most mundane diseases would require mediation by the doctor who would have to issue the prescription. And as the health-insurance industry grew up, the fact that insurance companies would only provide reimbursement for authorized procedures provided by authorized personnel, while protecting us from quacks, also forced us to get all medical care through professional medical channels. While each of these gatekeeping functions helped to ensure a high quality of medical care, it also offered the potential for abuse in the service of the doctors' economic interests.

That there was a tension between professional standards and commitments and economic incentives was recognized very early by medical organizations: Professionalization violated the rules of the marketplace. People were not free to enter medicine as they pleased, nor to offer whatever kind of medical service they wanted for whatever price they wanted. It was not left up to consumers to judge between various "brands" of care by choosing freely in an open market. The medical community judged that people lacked the specialized knowledge to make intelligent choices. Left on their own, they could easily be deceived and exploited by unprincipled charlatans.

So the profession of medicine protected consumers by imposing and policing standards. This gave the profession a monopoly on medical care; it protected the profession from the discipline imposed by a competitive market. In asking for and getting monopoly power over their profession, doctors were in effect asking their patients for trust, trust that they would adhere to professional standards, that they would judge one another, that they would never allow their monopolistic position to foster greed or carelessness. In return for this trust, organizations such as the AMA developed specific guidelines to keep medicine professional--to prevent it from becoming a business. As the AMA put it, "where physicians become employees and permit their services to be peddled as commodities, the medical services usually deteriorate, and the public which purchases such services is injured."

But nothing lasts forever. The tension between commercial and professional interests has been persistent, and over time, the commercial side has worn down the professional side. Over the last twenty years or so, the profession of medicine has given itself over almost entirely to commerce. Trust has been replaced by suspicion, and respect replaced by disdain, as modern doctors have come increasingly to be seen as driven primarily if not exclusively by the pursuit of wealth.

It has come to pass that the compromise between professionalism and commerce has degenerated into the full-scale embrace of commerce. When private hospitals refuse Medicaid patients because the reimbursement rate provided by Medicaid is too low to make the treatment of these patients profitable, commerce has won. And when studies report that uninsured patients lucky enough to be admitted to private hospitals receive worse care than insured patients (largely because of staff choices not to perform tests and procedures that are not absolutely mandated by the patient's condition, since these tests will not be paid for), commerce has won. When doctors are involved in kickback schemes, admitting patients to particular hospitals in return for referral fees, commerce has won. When specialists start selling shares in their practices to non-participating, but potentially referring primary-care physicians, commerce has won. When the CEOs of hospitals (even non-profit hospitals) start thinking of themselves as the heads of struggling businesses whose primary responsibility is not to community service, but to the bottom line, commerce has won.

As examples like these accumulate, and get reported, as these were, in daily newspapers and popular magazines, the public attitude toward the medical profession deteriorates. It becomes increasingly difficult to show doctors the respect and admiration they may once have received and deserved. The doctors, in turn, may decide that if they're going to be treated like ordinary businesspeople, they may as well act the part. It may not gain them respect, but at least they can be consoled with wealth.

The AMA, which previously tried to prevent the commercialization of medical practice, has apparently given up. While once it regarded advertising and entrepreneurial activities by physicians as unethical, it now officially sanctions both, presumably in acknowledgement of the cold economic realities of modern medical practice. Indeed, the AMA may even have given in to the temptation to make a virtue of its failure to prevent the penetration of commercial concerns into professional practice when, in a recent statement, it opined, "ethical medical practice thrives best under free market conditions, when prospective patients have adequate information and opportunity to choose freely among competing physicians and alternative systems of medical care."

This claim about the virtues of the market for "ethical" medical practice may be nothing more than a rationalization for its real virtue--income generation. Nevertheless, so many people who have criticized truly significant health-care reform proposals have done so on the basis of arguments about the wonder of market competition that the claim must be examined seriously. Since Adam Smith, proponents of the market have described it as a social miracle. Without planning, concern, trust, or love on the part of anyone for anyone else--without, in short, any virtues of character whatsoever--the market, they claim, will get society what it needs and wants, more efficiently than any other imaginable social arrangement. All we need to make the miracle happen is economic freedom and competition. We all know the drill by now, and most of us--even "liberal" Democrats--believe it. But it isn't true. Freedom and competition aren't enough. We also need information. We have to know enough about what's available and how to evaluate it if we are to use our economic freedom intelligently. Without information, we will be at the mercy of those who try to manipulate us into buying what they have to sell.

So what's the problem? The quote from the AMA that I just cited acknowledges the importance of "adequate information." We just have to make sure we go out and get it. But how feasible is this task? Forget for a moment about health-care decisions and think about something much more trivial and simple: your weekly trip to the supermarket. Choose a box of cereal from the hundreds on display. Should it be corn, rice, wheat, oats, bran, or mixed? Sweetened or not? With sugar or honey? "Natural" or not? And what about price? Now choose some laundry detergent. Liquid or powder? Scented or unscented? Cold water or warm water? With or without phosphates? Large, extra large, jumbo, super-colossal, or extra-super-jumbo-colossal economy size? Next pick a headache remedy. Aspirin, ibuprofin, or acetaminophen? Tablets, capsules, or caplets? 250, 350, or 500 milligrams? Buffered or plain? Store brand or national brand? You get the idea.

How much time would it take for you to gather all the information you need to make your weekly trip to the market the kind of informed activity that free-market enthusiasts celebrate? It's quite overwhelming, and for two reasons. First, there are too many options. Second, many of the things about which we have to choose are so complex that we couldn't possibly learn enough about them to make intelligent choices. Sure, we might devote ourselves to becoming expert about one or two things, but not all things. Instead, if we are to have any time in life actually to consume anything we buy, we have to rely on others to tell us what's good and what isn't. And this is in the supermarket!

When we shift our attention to high technology--stereos, VCRs, answering machines, faxes, computers, and the like--the problem gets worse. So we buy and study guides--consumer magazines--to tell us which stereo or laundry detergent to purchase, which movies to see, which restaurants to eat in. But when we use such guides, rather than doing without trust, we are relying on it. We have to trust in the people who write the guides. Why do we trust them? Because, we think (or hope), they, unlike the people who make and sell the products we buy, have no axe to grind. They, we think (or hope) have our interests at heart.

In a domain as complex as health care, where expertise takes years to acquire, we as "consumers" can't get "adequate information." We have no real alternative to trusting the people who provide the care. Thus, there is no way that a free market can be counted upon to provide us with what we need. As long as the providers have a significant commercial interest, as they obviously do in the current system, and will under any of the health-care proposals now getting serious consideration, expensive, often unnecessary, and sometimes inadequate treatment is virtually guaranteed to continue.

Since it is obvious that the goods and services we consume get more complex and varied all the time, market freedom grows ever more inadequate as a system for providing what people need. Not only is it true that most of us want to be able to trust our doctor. It's also true that most of us need to be able to trust our doctor. And only the kind of transformation suggested by Clinton's rhetoric, not his proposal, will start us moving on a path where eventually, such trust may be warranted. Since we can never do without trust, we should be focusing our energy and attention on what we must do to our system so that eventually our trust will be justified by the actions of the people on whom we bestow it.

Why have so many of us so willingly accepted the profit-based market system as the only possible framework for health-care reform? By doing so, we accede implicitly to the view that health care is a commodity. By doing so, we accede implicitly to the view that the profit motive is the engine for producing a just distribution of health-care services, surely an odd view in light of its failure to produce a just distribution of anything else. By doing so, we accede to the view that concern for the common good is for cocktail party discussion only--for rhetoric, not for social policy. Realism governs, and realists, in this worldview, are those people who assume that self-interest is the only genuine motive for action and that market freedom is the best structure for harnessing self-interest. So we accept the extraordinarily pinched possibilities for health-care reform that people in power lay before us, because to do otherwise is to brand oneself an idealist, a romantic, and a fool.

TIKKUN has been a forum for those thinkers and writers who refuse to accept the market-based limits to the health-care and other social-policy debates. It has instead spoken persistently and bravely about the "politics of meaning," and in so doing, it has taken the hit for the rest of us. Had it not been for Hillary Rodham Clinton's invocation of a politics of meaning in a speech she gave in April 1993, the "sophisticated" (read cynical) media would probably simply have ignored questions of meaning and morality no matter how many editorials Michael Lerner wrote. When Mrs. Clinton said that "We need a politics of meaning...We need a new definition of civil society which answers the questions posed by both market forces and governmental ones, as to how we can have a society that fills us up again and makes us feel that we are part of something bigger than ourselves," meaning and morality could not simply be ignored. So instead, the pundits scoffed at her embrace of these concerns, ridiculing them or dissecting them in the language of realpolitik ("will this kind of talk help or hurt this or that candidate, or this or that piece of legislation"), the only language that our media pundits are able to understand.

The profit-driven motives of the free market have so thoroughly pervaded the media that the folks who shape our opinions can hardly be expected to challenge the people who sign their paychecks. Rather than challenging what is and imagining alternatives, they accept what is as inevitable and lampoon alternatives. Even when the media appear to be taking concern for meaning and morality seriously, their coverage drips with cynicism. Newsweek had a cover feature on what it called "the politics of virtue" in June 1994. But the politics of virtue is all that it was about--who's playing the virtue game and who's likely to win it; nothing about the substance of the claims about the need for virtue that people on both the Left and the Right were making. And Newsweek had a poll (of course). "Who is to blame for the problem of low morals and personal character in this country?" it asked. "Family breakdown" led the list, followed by "individuals themselves," "TV and other popular entertainment," "government and political leaders," and "the schools." The hallowed and pervasive market system, which caters to selfishness and makes virtue a sucker's game, wasn't even an option.

To be a virtuous society, we must have virtuous institutions. Virtue is simply too much to ask of people acting alone. And conservatives are right when they say that government can't make people virtuous. It can help, but it certainly can't do the job alone. For this reason, the right kind of health-care reform is crucial, and the Clinton proposal profoundly disappointing. Reformed properly, health care could again become a profession instead of a business. It could provide a living example--one that every member of society encountered on a regular basis--of how to live a life that "fills us up again and makes us feel that we are a part of something bigger than ourselves."

In what appears to be the failure of even modest reform of the health-care system, the Clintons may actually be getting a second chance. Maybe in the next legislative year, they can do it right. Maybe they can take their own rhetoric seriously and go straight to their constituents with a proposal that will not only improve the quality and distribution of health care, but also be the vanguard for the reconstruction of America's soul.

Barry Schwartz is a professor of psychology at Swarthmore College. An expanded version of the arguments in this article, as applied to health care and other aspects of modern life, can be found in his new book, The Costs of Living: How Market Freedom Erodes the Best Things in Life (W.W. Norton).

Source Citation

Schwartz, Barry. 1994. The Meaning of Health and the Health of Meaning. Tikkun 9(6): 19.