Tags: Who | Should | Make | Medical | Decisions?

Who Should Make Medical Decisions?

Friday, 08 June 2007 12:00 AM

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 Dr. Jane Orient, 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 Web site "Many politicians simply don't believe individuals can make decisions about their own healthcare. 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 www.capitalresearch.org/pubs/pubs.asp?ID=553 and www.capitalresearch.org/pubs/pdf/CC0207.pdf once the Web site 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 healthcare 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

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.

Robert J. Cihak, M.D., is a senior fellow and board member of the Discovery Institute and a past president of the Association of American Physicians and Surgeons. Michael Arnold Glueck, M.D., comments on medical-legal issues and is a visiting fellow in economics and Cctizenship at the International Trade Education Foundation of the Washington International Trade Council.


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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...
Friday, 08 June 2007 12:00 AM
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