Thursday, April 21, 2011

Krugman’s Blind Spot About Health Care

Am I the only one who thinks that it’s more than a little bizarre that Paul Krugman is not only making this argument, but is downright indignant about having to make it at all?
“I keep encountering discussions of health economics in which patients are referred to as ‘consumers’, after which the usual mantra of freedom of choice is invoked on behalf of voucherizing Medicare, or whatever.

“We used to know better than this.

“Medical care is an area in which crucial decisions — life and death decisions — must be made; yet making those decisions intelligently requires a vast amount of specialized knowledge; and often those decisions must also be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping.

“That’s why we have medical ethics. That’s why doctors have traditionally both been viewed as something special and been expected to behave according to higher standards than the average professional. . . .

“The idea that all this can be reduced to money — that doctors are just people selling services to consumers of health care — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.”
Got that? While autonomy may be a fine thing for a consumer deciding whether to buy grapes or olives with a marginal dollar, we shouldn’t have any qualms about surrendering our autonomy to trained professionals when it comes to “life and death decisions” about our lives. Our health is just too damned important to us for us to insist in having a say in what health care we receive. Anyone who thinks otherwise must not have heard about “medical ethics.”

Of course, Krugman’s reference to medical ethics is self-refuting because patient autonomy is one of its foundational principles. Granted, a doctor generally knows better than her patient what treatment is indicated for the patient’s condition. Yet that doesn’t imply that the doctor’s expertise puts her in a position to decide responsibly whether it’s in the patient’s interest to undergo that treatment. Indeed, under normal conditions, it would be the gravest breach of medical ethics imaginable for the doctor to initiate the treatment without the patient’s informed consent.

We think autonomy matters to medical patients for the same reason it matters to everyone else. Generally speaking, we understand one’s interests to be largely a function of satisfying one’s values, whatever they may happen to be. Accordingly, the best evidence of what one’s real interests are is generally what one prefers under conditions that facilitate sound deliberation (when one is of sound mind, apprised of all the relevant information, insulated from psychological and social pressures that tend to cloud judgment, etc.). In the case of contemplated medical treatment, most of us therefore think the best way to identify and promote the patient’s interests is not to concentrate decision-making power in the hands of the doctor, but to make the doctor’s expertise and conditions favorable to deliberation available to the autonomous patient.

Why is Krugman forgetting these perfectly obvious considerations when he hears people expressing unease at the prospect of delegating decisions implicating their health to a panel of experts that knows nothing about their peculiar medical condition? The debate over health care reform is, among other things, one long and complicated argument about whether surrendering your autonomy to government-appointed experts is a better or worse deal than surrendering it to a private insurance company with which you contracted autonomously before you got sick.  But evidently Krugman doesn't think he even has to allude to that argument here.  As far as I can see, he's just zealously defending his class interest as a credentialed expert.

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