Monday, April 19, 2010

Social Justice and the Framing of the Healthcare Debate about fairness and individual freedom

Two years ago, I published a blog commentary about what I now call the"social justice revolution" in medicine. I wrote about about what-not too long ago-was a simple two person transaction between physician and patient and some aspects of the path taken to the current situation where a number of major physician organizations ( e.g. AMA,ACP) and medical education bodies ( e.g. ACGME) swear allegiance to the concept of social justice. inculcate trainees with its mantra and charge the physician with a greater task, that of working towards social justice . With the passage of the health care deconstruction-reconstruction bill we see those organizations taking public pride in the role in moving towards the goal of social justice in the area of health care.

Here is what I said then, slightly edited and brought up to date:

In the not too distant past, but well before the current generation of medical students and house officers went to college, a person in the United states might go to a physician with some medical problem and be charged for the medical services and then pay for the service either out of pocket or pay and then file with an insurer to get or all some of that reimbursed. It was a private transaction between two persons in a country in which private transaction between individuals was so normal as to not attract any attention. The ethics or justice of such a transaction was simply not a topic for discourse.

In this not too distant past, the ethics of the medical profession was generally well defined and could be expressed in a few simple sentences and seemed to be firmly imprinted in the physician's mind as part of the transition process from a lay person to a physician.

It was about respect for autonomy, beneficence, and non-maleficence. It was all about the physician and the patient-do no harm, act in the patient's best interest and respect the patient's views and wishes . It was a two party deal, with the physician fulfilling a fiduciary duty to the patient.

The AMA 's 2001 published version of the ethical principles is a bit more detailed but contained little to be contentious about and does not contain the word "justice". More on that latter.

Later, a fourth major principle was grafted on the the ethical framework. Justice was the new kid on the block. In the beginning, there was more than a little ambiguity in this term as there are more than one definition of justice. It became quite clear what was mean by justice with the publication of the Medical Professionalism in the New Millennium.A Physician Charter.( Annals of Internal Medicine 5 Feb. 2002, vol 136 pg 243-246.)

The justice to which physicians were admonished to strive was social justice. Thomas Sowell makes the distinction between the traditional American society's version of justice and social justice in this way. On the one hand, we have justice as basically applying the same rules and standards to everyone -equality of opportunity or equality under the law. On the other hand, we have the redressing of those inequalities that proponents characterize as the fault of society-equality of outcome. In the latter, whatever characteristics at issue are thought to be unequally "distributed" between various groups (income,medical care,access to swimming pools) should be "redistributed". Whatever may have been distributed by acts of God, accidents of history, an uncaring society , or whatever, to achieve social justice someone or something needs to correct the maldistribution. When redistribution is needed, someone or something has to make it happen and force or the threat of it is required.I am aware of no third way.

Making everything right would appear to be quite a task to assign to busy, practicing physicians so there was little surprise by the results of a survey,that I talk about here, that indicated that concern for social justice did not take up a large amount of a physician's times or enter heavily into his daily clinical decisions and activities.

Not only it is quite a task, proponents of new professionalism tell us in August 2007 JAMA article that after "further reading" of the tenets of the new professionalism they realized that physicians alone could not do it by themselves. So who should do it? We are told it should be a medical societal alliance. My translation is that again we told medicine is far too important to be left to the individual patient and the individual physician and we need more powerful players, probably the government,possibly big insurance and well connected medical academic intellectuals such as those who write such articles to mobilize things and makes the inequities right.

Thomas Sowell writes about a "moralistic approach to public policy" in the concluding section of his book, "Knowledge and Decisions". I characterize the authors of the New Medical Professionalism with their insistence of physician's allegiance to social justice - in a society where there is no dominant secular view of justice at all-as medical moralists.

In Sowell's section entitled "Embattled Freedom" we read ...The desire for freedom and its opposite,power, are as universal as any human attributes....The moralistic approach to public policy is not merely a political advantage for those seeking concentration of power. Moralism in itself implies a concentration of power...The reach of national political power into every nook and cranny has proceed in step with campaigns for greater "social justice".

The recent, at-times heated,discussions (see here for some links) about the ethics of retainer practices illustrate how the concept of social justice as an alleged medical ethical imperative as promulgated by the medical moralists has framed the discussion and attempts to control the dialog.

With the passage of the health care bill and the massive uncertainty about the bill's meaning some fear for the future not only of retainer practices but more broadly of the individual's prerogative to seek out and pay for her own care.

In a world in which talk about equality of outcome and fairness seemed to have achieved a rhetorical prominence and a position allegedly above further discussion, can better or more medical care for those who can afford it be allowed? See here for the beginning of a commentary about that and here for a discussion about the likely origins of the bill.

If and when the option of individual prerogative is excluded it will not be the result of a vigorous national debate but its components will quietly be chipped away by sundry bureaucratic entities that have emerged almost unseen from the seemingly endless,mild numbing and intentionally indeterminate verbiage of the health care bill. To the extent that any debate at all occurs I doubt that those of us who hang on the notion of individual freedom and the right to pay for one's own medical care will find support from the major medical professional organizations who supported the bill

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