Thursday, September 06, 2007

Conflicting Goods?

I've often been suspicious of the starring role played by the principle of autonomy in most medical ethics treatises.

So it's interesting--to say the least--to hear a presidential candidate propose a solution to our country's health care dilemmas that proposes limiting patient autonomy in a substantial way--or at least penalizing the irresponsible exercise thereof.

John Edwards (Does anybody else keep accidentally calling him Jonathan Edwards?) recently proposed health care policy that would mandate certain preventative measures, including annual checkups and mammogram screens.

Now, this is a very interesting proposal. In many ways, it naturally follows from the combination of the logic of the market and the logic of liberalism, both of which also depend on autonomy as their chief good. Medicine has been almost completely subsumed into both--it has become an enterprise almost completely dominated by its economic side, and government intervention into and regulation of the practice of medicine is taken as normative. (Ask even the most ardent libertarian whether he'd like his son to be operated on by a doctor who was not board-certified.)

So, assuming medicine to be a predominantly economic enterprise, and assuming government responsibility to make this economic enterprise run well, it makes sense for the government to exercise its authority by incentivising and disincentivising behaviors that have economic consequences within the system.

This means you have three disciplines or systems which derive their internal logic from a primary commitment to autonomy, combining in such a way that virtually demands a limitation of individual autonomy. Fascinating.

In all honesty, though, as much as I loathe Edwards' proposal, I think he is the first candidate whose proposals show that he understands the complexities of the health care problem. Few of the other proposals I've seen seem to take seriously the complex interplay of economics, psychology, law, and biology that comprises health care. I'm not sure he adequately addresses the dynamics of the patent system or litigiousness, but he has covered more bases than most people.

The only bit of utter cluelessness came when he said, in response to the question of whether people would find this too invasive, "We mandate public education—public or private—and no one minds that."

Now, I know he's only homeschooling his kids this year so that they can spend time together as a family while he's campaigning. So he's not a hard-core homeschooler. But still, you'd think he'd have heard of a movement of a couple million people who decidedly "mind that." Or maybe have read of the violent resistance that attended the introduction of compulsory schooling?


JoVE said...

It seems to me that it is precisely the desire to maintain the free market that leads to the coercive element you describe.

If they didn't need to think about affordability, many people would have those preventative things anyway. Sure some wouldn't (just like a small proportion of the population don't use public schools) but it wouldn't change the overall impact on the public good of reducing acute care costs because most people would do it voluntarily.

You only need coercion to make people spend their own money that way.

Heather W. Reichgott said...

Pragmatically speaking, the good this would provide is that preventative-based health care is FAR cheaper, and of course FAR healthier, than health care that only pays attention to you once you have an emergency.

Prevention would cut way down on the number of people who use the ER as primary care.

What I don't get, though, is why Edwards suggests that preventive care be mandatory. I mean, if we just made it FREE, lots of people would go and use it, thus reducing the amount of super-expensive ER visits, the strain on their own health and the strain on the health care system.