Tuesday, April 13, 2010

Transactional politics,the public good,social justice and the health care bill

A recent commentary by Bob Doherty,lobbyist for the American College of Physicians (ACP), included remarks critical of what some consider a growing trend in world of national politics and legislation,a phenomenon described as "transactional politics". These remarks appear as part of a reply to and a defense against some comments that he has received on his blog from internists who have expressed dissatisfaction with the ACP position of support for the recently passed health care bill.

Transactional politics ( "TP" for short) essentially means the horse trading that goes on with one group promising to do this for someone if someone does that for them. We are talking about getting votes to favor one group or another by promising something, such promise usually to involve voting .Basically vote for me and I will do this (give you health care,give you clean air, whatever).

Some have contrasted TP with another concept with the same initials , "transformational politics" which means the situation in which one acts to further the general good even if they may have to make some sacrifices themselves. In general, progressives typically believe, or claim at least,that they act in the public good so they are frequently transforming or trying to at least.

Doherty defends the ACP and their role in the health care debate by saying while the bill doesn't contain everything that physicians (including the ACP leadership) want but after all they are not a labor union and their motives include not only the interests of the physicians but of the patient and the common good. In short, they are acting in the public good. So while we didn't get everything we wanted we acted in the public interest and for the common good, with the implied contrast with other groups who lobby for their own focused self interest.

He quotes from the ACP's mission statement:

the principal goal is "To advocate responsible positions on individual health and on public policy relating to health care for the benefit of the public, our patients, the medical profession, and our members."

The message seems to be that the ACP is not engaging in transaction politics but they are working for the benefit of the public. I wonder what qualifies the ACP to make that claim while some other lobbyists are just doing venal transactional politics?

When is the last time a politician or a lobbyist favored a bill that he did not characterize as being in the public good or public interest.The words "public good" have largely replaced the words "God's Will" in the discourse surrounding advocacy for or against one thing or another. Preachers on both sides of the Civil War assured their congregations that God was on their side. Now policy advocates and opponents both seem to implicitly claim that they are blessed with some unique insight analogous to the divine knowledge that allowed the clergy to reassure their flock of the righteousness of the their cause. The thing about a gratuitous assertion is that it can be contradicted with a gratuitous denial with equal lack of need for evidence.

Whether a given policy position is for the public good is in the eyes of the claimants.

Mr. Doherty then quoted the Charter on Professionalism ,a statement by the ACP ( and other groups as well) on what modern medical ethics should be:

The Charter states that "the medical profession must promote justice in the health care system, including the fair distribution of health care resources" and "A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession."
( my bolding ,his use of italics)

Justice in the sense of the above quote would seem to mean social justice or distributive justice, a viewpoint that looks to equality of outcome not necessarily solely to the equality of opportunity. A number of medical bloggers, including me, have written about social justice in the context that the claim of advocacy for social justice is a necessary arrow in the quill of the ethical physician. See here. I reject the assertion that social justice is the justice that ethical physicians must adhere to. More than that, my assertion is that a mixed fidelity to the patient and to some general societal good or welfare may destroy the very essence of the traditional physician-patient relationship,the fiduciary responsibility to the patient.

Several years ago, I asked "Can the traditional medical ethical prime directive of placing the individual patient's interest first survive in a financial environment in which physician autonomy is greatly diminished and income for most physicians is controlled by third party payers?"

Before that , Dr. Edmund D. Pellegrino, whose credentials in the field of medical ethics are not likely to be questioned, asked in 1995 (JAMA,May 24/31,1995,Vol 273,no 20,) " Is medical ethics a social, historical, or economic artifact?Or are there some universal , enduring principles?

I maintain that the Charter on Professionalism answered that question in the negative.

The ACP, ABIM and the European Federation of Internal Medicine joined forces to formulate what was called the New Professionalism in which physicians were told that they had an ethical obligation to strive for Social Justice. This joint effort of re-doing medical ethics by several medical organizations was said to be necessary as the "old ethic" needed to be revised to align itself with the new economic environment in which physicians now lived and "medicine's commitment to the patient was being challenged by external forces of change within our society...

So, the ACP and others declared that the old ethic had to be revised. Yet, in a recent exchange between Dr. Richard Fogoros and Dr. Virginia Hood who represented ACP , Dr Hood seemed to maintain that really there was no conflict at all between the individual patient's well fare and the good of the herd and all the new professionalism did was to tell docs to just practice good medicine. At least, that was Dr. Fogoros's take on the non-debate, a view with which I agree. See here for details of that exchange, The issue is the conflict between the individual and society and that ACP leaders may have chosen not to fight that battle again having declared victory.

So the defense which the ACP's advocate choose to construct to justify their support of the health care bill consisted of:

1.We supported it because the bill did contain several items consistent with ACP mission and goals (e.g. providing health insurance for millions of previously uninsured citizens)
2.ACP will continue to fight for other things important to physicians ( e.g., repeal of the SGR compensation cuts)
3.ACP's lobbying effort is not your typical lobby effort but rather their proposals are also in the public interest.
4.Physicians have an ethical duty to promote social justice which many believe this bill accomplishes.

Arguments 1 and 2 hold water.More folks will be insured and the ACP has advocated greater access for years. I have no doubt they will continue to advocate a more reasonable compensation system for CMS and for malpractice tort reform.

However, Argument 3 is no more that a gratuitous assertion and argument 4 relies on the assumption that social justice is the only concept of justice appropriate to the modern day physician and that the concept of social justice actually has substantive meaning.

I have no reason to believe other than that the leadership of the ACP is populated by conscientious, well intended physicians who are dedicated to their profession and have given the matter of their advocacy for medical policies much thoughtful consideration and believe they are doing the right thing.

Acceptance of the social justice concept and the imperative to work for that end is likely part of the world vision of at least some ( most?) of the ACP leadership. To the extent that health care bill presents a victory for proponents of social justice, the actions of the ACP are consistent with their expressed core beliefs.

Physicians whose views can be characterized as progressive may be pleased with the bill, warts and all, while for libertarians and conservatives, not so much.The reaction of many physicians in opposition to the health care bill provides some evidence that the progressive view is not shared by all.

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