Practicing medicine for the common good

In a recent New England of Medicine article titled “Considering the Common Good—The View from Seven Miles Up,” Dr. Martin Shapiro tells a story that serves as a parable for a more general point:  Instead of only considering the best interests of individual patients, American physicians should adopt “a more communitarian approach to decision making” and consider “the implications of individual clinical decisions for other patients and society as a whole.”

The parable is as follows: two sick patients are aboard an airplane, each with his own physician.  The first one is terminally ill and on his way home; the second one has a grave illness but stands a small chance of surviving.  A decision to land midway must be made in flight, and it pits the interests of the one against those of the other.How are the physicians to decide?  If they only consider the individual interest of their patient, a conflict will arise and the best outcome may not be reached.  Shapiro claims that similar situations commonly occur in healthcare, where pooled resources must be distributed among many patients.  Undue attention to patient autonomy can lead to wasteful care, or care that has little value.

The remedy?  American physicians should follow the lead of other industrialized nations that have adopted a single payer system, because in such systems, “some decision making operates on the assumption that everyone — patients, providers, and policymakers — is in the same boat (or airplane) and that each decision affects others on the ship.”

Shapiro’s parable is an illustration of Spaceship Earth ethics, a “term usually expressing concern over the use of limited resources available on Earth and encouraging everyone on it to act as a harmonious crew working toward the greater good.”  Spaceship Earth ethics is increasingly promoted by professional organizations, such as the American College of Physicians, as a new medical ethics for the twenty-first century.

Unfortunately, proponents of Spaceship ethics do more than simply encourage people to work harmoniously. They invariably promote the establishment of coercive, centrally-planned directives that sway decision making along dubious utilitarian principles.

Shapiro denies proposing coercive rules: “…legislators [should] not to interfere with clinical discussions and decisions by invoking highly charged notions like ‘death panels.'”  But if legislators should not interfere with clinical decisions, why point to single payer systems as models to follow?  Single payer systems are precisely systems where resources—hospitals, equipment, staffing—are allocated according to bureaucratic decisions, and the allocation and availability of resources is one of the most important factors to influence medical decisions.

As it turns out, the recommendations offered by Shapiro amount to an incoherent and misleading mishmash.  The most important incoherence is his talk about the common good as if it were an objective, fixed entity that one could apprehend, appraise, and aim toward, independent of the individual needs of the members the community.

In fact, his parable testifies to the opposite:  The reason we could agree that landing the plane in Chicago was not optimal from the standpoint of the common good was because the common good was here limited to two particular cases about which we have full knowledge and to two fixed options using known finite resources.  The trade off could be explicitly articulated.

That’s a far cry from the situations Shapiro wants us to extrapolate to, such as decisions to keep someone alive in the ICU.   In such cases, no one can have full grasp of the impact a decision could have on the collectivity, and the resources placed at the disposal of those involved seem limitless.

Of course, Shapiro chooses his examples carefully: intensive care “for the dying patient,” chemotherapy “at the end of life,” expensive imaging tests “for short term back pain,” feeding tubes for “end stage dementia.”  All of these phrases either presuppose knowledge of circumstances or presuppose futility.

What Shapiro and advocates for the new medical ethics refuse to acknowledge is that the problem of over-utilization comes from the moral hazard associated with third-party payment.  It’s because payment for care is decentralized and collectivized and, therefore, because value is divorced from price, that we are experiencing an epidemic of unnecessary care.

Paradoxically, Shapiro alludes to the enclosure movement which, at the end of the medieval period in England, began to limit overgrazing and depletion of resources.  Although the history of that movement is complex, and its interpretations vary, taking Shapiro’s argument at face value should move us toward a system where decisions are made locally on the basis of property rights.¹

@michelaccad Common good has to be considered, that’s the whole point. How does Hayek square that circle?

— Albert Chancery (@AlbertChancery) May 26, 2016

Care for the common good is a moral imperative, I agree, and resources must be used mindfully and as sparingly as possible.  But the common good is not an idealized concept that can be entrusted to bureaucrats.  The common good emerges when benevolent physicians help individual patients within the constraints of their legitimate resources.  As Murray Rothbard has convincingly demonstrated in his critique of mainstream (utilitarian) welfare economics, any other arrangement can only make the population worse off.

Medical care can only have one end, the care of a given patient.  A dual mandate to simultaneously care for individuals and populations is inherently confused, and letting our decisions be influenced by a mythical “respect for the commons” is counterproductive to the true good of society.

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Note:

1. Incidentally, Shapiro also overlooks that the ultimate decision to land the plane rests on the captain of the ship, as a delegate of the ship’s property owners.  Again, with knowledge of the particular circumstances, it is more than likely that the captain would also come to the best decision for the common good.