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Monday, January 07, 2008

Retainer Medicine,Social Justice and the importance of framing the debate

In the not too distant past, but well before the current generation of medical students and house officers were born, a person 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 out of pocket 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 the 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.
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.

The AMA 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. In the beginning there could have been a bit of ambiguity as there are many definitions of justice. But 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 of which they spoke 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 mal-distribution. When redistribution is needed, force or the threat of it is required.

Making everything right would appear to be quite a task to assign to busy, working in the trenches docs, so one should not be surprised by the results of a survey,that I talk about here, that indicated that concern for social justice does 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 that physicians alone cannot do it. 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,likely 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.


Anonymous said...

Dr. Gaulte,

Thank you for this concise survey of the issue. To me, the question of social justice boils down to this: Does social justice imply attempting to achieve equal opportunity, or equal outcomes?

America's foundational document, the Declaration of Independence, explicitly calls for equal opportunity under the law. The founders would have been aghast at the notion that the goal of society should be equal outcomes.

This, simply, is because achieving equal outcomes necessarily requires a supremely powerful central authority that can forcibly and arbitrarily redistribute wealth (and any other commodity required for homogenation of outcomes). This is explicitly what the founders were fighting to avoid.

Requiring "social justice" to be framed as the need for equal outcomes has always been, and will always be, a demand for such an all-powerful central authority. That the desirability of this variety of social justice is taken today as a "given" by a great part of the mainstream is, to say the least, disturbing. Do these people understand what they're asking for?


james gaulte said...

Cynically, I believe many who take social justice as a given do not really grasp what it means and how it works.I also believe that many of the advocates for social justice in various contexts know exactly what it entails.

JoshMD said...

Your eloquent arguments against the "social justice" are beautifully reminiscent of Ayn Rand's "The Virtues of Selfishness."

Strong work Sir.

Thank you.

Anonymous said...

My take is that the notion of justice as a ethical precept has been taught to the current generation of medical students and house officers to the extent that the debate is framed or stacked in the favor of the notion of social justice. Some docs such as Panda Bear seem to see through it anyway.

Anonymous said...

Dr. Rich,

The opportunity vs. outcomes idea of justice is an important one.

I think a sophisticated response from an advocate of the "equal outcomes" agenda would say the following:

"yes, I agree the ultimate goal is equal opportunity. However, if we had TRUE equality of opportunity like we all want, we would see more equality in our outcomes across racial,socioeconomic, and gender lines. Since we persistently see inequality of outcomes along those lines, we, by definition, must not have TRUE equality of opportunity. Therefore we need to address these inequalities with redistribution until the outcomes come in line with our expectations."

Debating this point is where the money is.

james gaulte said...

to anon.8:16 AM
I believe the key words there are "we need" and "come in line with our expectations".Who gets to be the "we" and whose expectations are elevated to the level of being the ultimate arbiter? It is the age old tension between freedom and power.

Anonymous said...

"We" is simply our elected officials carrying out "justice."

"our expectations" are simply statistically proportionate outcomes based on societal makeup. You know, what you would expect if things like gender, racial, and class discrimination weren't in the way

See, that was easy. :)