This lecture was first delivered on April 14,1985 at the Ford Hall Forum in Boston.
I wish to acknowledge the invaluable assistance given to me in the preparation of this lecture by my brother, Dr. Michael Peikoff, who is a surgeon in Nevada.
One day, when you are out of town on a business trip, you wake up with a cough, muscle aches, chills, and a high fever. You do not know what it is, you start to panic, but you do know one action to take: you call a doctor. He conducts a physical exam, takes a history, administers lab tests, narrows down the possibilities. Within hours, he reaches a diagnosis of pneumonia and prescribes a course of treatment, including antibiotics. Soon you begin to respond, you relax, the crisis is over. Or: you are getting out of your car, you fall and break your leg. It is a disaster, but you remain calm, because you can utter one sentence to your wife: “Call the doctor.” He proceeds to examine your leg for nerve and blood-vessel injury, he takes X-rays, reduces the fracture, puts on a cast; the disaster has faded into a mere inconvenience, and you resume your normal life. Or: your child comes home from school with a stabbing pain in the abdomen. There is only one hope: you call the doctor. He performs an appendectomy—the child recovers.
We take all this completely for granted, as though modern drugs, modern hospitals, and modern doctors were facts of nature, which always had been there and which always will be there. Many people today take for granted not only the simpler kinds of medical intervention, such as the ones I just mentioned, but even the wonder cures and wonder treatments that the medical profession has painstakingly devised—like the latest radiation therapy for breast cancer, or the intricate delicacy of modern brain surgery, or such a breathtaking achievement as the artificial-heart implants performed by Dr. William C. DeVries. Most of us expect that the doctors will go on accomplishing such feats routinely, steadily removing pain and thus enhancing the quality of our life, while adding ever more years to its quantity.
America’s medical system is the envy of the globe. The rich from every other country, when they get sick, do not head for Moscow or Stockholm or even London any more; they come here. And in some way, despite the many public complaints against the medical profession, we all know this fact; we know how good our doctors are, and how much we depend on their knowledge, skill, and dedication. Suppose you had to go on a six-month ocean voyage, with no stops in port, with ample provisions and sailors, but with only one other profession represented on board in addition, and you could decide which it would be. Would you ask for your lawyer to come along? your accountant? your Congressman? Would you dare even to ask for your favorite movie star? Or would you say: “Bring a doctor. What if something happens?” The terror of having no answer to this question is precisely what the medical profession saves us from.
I am not saying that all doctors are perfect—they are not; or that they all have a good bedside manner—they do not; or that the profession is free from flaws—like every other group today, the medical profession has its share of errors, deficiencies, weaknesses. But these are not my subject tonight, and they do not alter two facts: that our doctors, whatever their failings, do give us the highest caliber health-care in world history—and that they live a grueling existence in order to do so.
I come from a medical family, and I can tell you what a doctor’s life is like. Most of them study non-stop for years in medical school and then work non-stop for the rest of their life. My own father, who was a surgeon, operated daily from 7 a.m. until noon and then made hospital rounds; from 2 to 6 p.m., he held office hours. When he came home for dinner, if he did, the phone never stopped ringing—it was nurses asking instructions, or doctors discussing emergency cases, or patients presenting symptoms. When he got the chance, usually late at night or on Sundays after rounds, he would read medical journals (or write for them), to keep abreast of the latest research. My father was not an exception. This is how most doctors, in any branch of medicine, live, and how they work.
The profession imposes not only killing hours, but also continuous tension: one way or another, doctors deal all the time with crisis—with accidents, diseases, trauma, disaster, the imminence of death. Even when an ailment is not a mortal threat, the patient often fears that it is, and he must be reassured, nursed through the terror, even counseled psychologically by the physician. The pressure on the doctor never lets up. If he wants to escape even for the space of a single dinner on the town, chances are that he cannot: he will probably get beeped and have to rush to the emergency room just as the entree is being served.
The doctor not only has to live and work in such a pressure cooker, he has to think all the time—clearly, objectively, scientifically. Medicine is a field that requires a vast fund of specialized theoretical knowledge; to apply it properly to particular cases, the doctor must continuously make delicate, excruciatingly complex decisions. Medical treatment is not usually a cut-and-dried affair, with a simple, self-evident course of action; it requires the balancing of countless variables; it requires clinical judgment. And the doctor must not only exercise such judgment—he must do it fast; typically, he has to act now. He cannot petition the court or his client or any employer for a postponement. He faces daily, hourly, the merciless timetable of nature itself.
What I personally admire most about doctors is the fact that they live this kind of life not out of any desire for altruistic self-sacrifice, but selfishly—which is the only thing that enables them to survive it. They love the field, most of them; they find the work a fascinating challenge in applied science. They are proud men, most of them, with an earned pride in their ability to observe, evaluate, act, cure. And, thank God, they expect to be rewarded materially for their skill; they.want to make a good living, which is the least men can offer them in payment for their achievements. They make that living, as a rule, by standing on their own, not as cogs in some faceless, government—subsidized enterprise, but as entrepreneurs in private practice. In this regard, the doctors are among the last of the capitalist breed left in this country. They are among the last of the individualists that once populated this great nation.
Ladies and gentlemen, if I knew nothing about today’s world but the nature of our politicians and the philosophy represented by the medical profession, I would predict an inevitable clash, a catastrophic clash, between the two: between the government and the doctors. On purely theoretical grounds, I would predict the destruction of the doctors by the government, which in every field now protects and rewards the exact opposite of thought, effort, and achievement. This evening, I want to tell you that this catastrophe is actually taking place, and in what manner, and how it will affect your future as well.
To understand what is happening in medicine today, we must go back to the beginning, which in this case is 1965, the year when Medicare and Medicaid were finally pushed through Congress by Lyndon Johnson. Medicare, as you may know, covers most of the medical expenses of those over 65, whatever their income. Medicaid is a supplemental program for the poor of any age.
Those of us who opposed the Johnson plan argued at the time that government intervention in medicine is immoral in principle and would be disastrous in practice. No man, we claimed, has a right to medical care; if he cannot pay for what he needs, then he must depend on voluntary charity. Government financing of medical expenses, we argued, even if it is for only a fraction of the population, necessarily means eventual enslavement of the doctors and, as a result, a profound deterioration in the quality of medical care for everyone, including the aged and the poor.
The proponents of Medicare were unmoved by any arguments. Altruistic service to the needy, they said, is man’s duty. It is degrading, they said, for the elderly to be dependent on private charity; a “means test” is incompatible with human dignity. Besides, they added, the government would not dream of asking for any control over the doctors or over their methods of patient care. All we want the state to do, they said, is pay the bills.
Well, it is now 1985. Let us look at what actually happened.
The first result of the new programs should have been self-evident. Suppose we apply the same principle to nutrition. Suppose President Johnson had said: “It is unfair to have to pay your own food and restaurant bills. Men have a right to eat. Washington, therefore, will pick up the tab.” Can you project the results? Can you imagine the eating binges, the sudden mania for dining out, the soaring demand for baked peacock tongues and other gourmet delicacies? Do you see Lutece and the “21” Club becoming nationally franchised and starting to outdraw McDonald’s? Why not? The eaters do not have to pay for it. And the food industry, including its most sincere members, is ecstatic; now that the money is pouring from Washington into the grocery chains and the restaurants, they can give every customer the kind of luxury treatment once reserved for millionaires. Everybody is happy—except that expenditure on food becomes so great a percentage of our GNP, and the drain on the Federal treasury becomes so ominous, that every other industry starts to protest, and soon even the bureaucrats begin to panic.
This is what happened to medical spending in the United States. The patients covered by the new programs no longer had to pay much attention to cost—that was the whole purpose of the programs. And the health-care professionals in the beginning were generally delighted. Now, many of them felt, the sky is the limit, and they proceeded to build hospitals, purchase equipment, and administer tests accordingly. Medical expenditures in the U.S. were 4.3% of GNP in 1952; today they are about 11%, and still rising. Medicare expenditures doubled from 1974 to 1979, doubled again by 1984, and are expected to double again by 1991, at which time, according to most current estimates, the Medicare program will be bankrupt. Something, the government recognized, has to be done; we are going broke because of the insatiable demand for medical care.
The government did not decide to cancel its programs and return to a free market in medicine—when are disastrous government programs ever canceled? Instead, it did what governments always do: it decided to keep the programs but impose rigid controls on them. How? The first step was a campaign to force hospitals not to spend much on Medicare patients, no matter what the effects on the health of those patients.
We will no longer, officials said, pay hospitals a fee for each service they render a Medicare patient. That method of payment, they said, simply encourages spending. Instead, we will pay according to a new principle, DRGs. Remember those letters: DRG. They represent the first major assault by the government against the doctors and their patients. It is not yet the strangulation of the medical profession. But it is the official dropping of the noose around their necks.
DRG means “diagnosis-related group.” According to this approach, the government has divided all ailments into 468 possible diagnoses, and has set in advance a fixed, arbitrary fee for each: it will pay a hospital only what it claims is the average cost of the ailment. For example, for a Medicare patient in the Western Mountain region who is admitted to a hospital with a heart attack and finally recovers enough to go home, the government now pays the hospital exactly $5094—no more and no less. And it pays this amount no matter what the hospital actually does for the patient, no matter how long his stay or how short, no matter how many services he requires or how few. If the patient costs the hospital more than the government payment, the hospital loses money on him. If he costs less, the hospital makes a profit.
Let us pursue the heart-attack example for a moment. Here is a fictional story now in process of becoming reality around the country. A man suffering from severe chest pains is taken by ambulance to the hospital. He receives certain standard tests, including a cardiogram, then is moved to the Intensive Care Unit, where his vital signs are continuously monitored. His doctor thinks that in this instance a further test, an angiogram, is urgently indicated; this test would outline the arteries of the heart and indicate if one is about to close off, an event that could be fatal. The hospital administrator protests: “An angiogram is expensive. It costs up to $1000, about 20% of our total fee for this man, and who knows what else he’s still going to cost us? You can’t prove this test is necessary. Let’s wait and see.” The test is not given. Maybe the patient lives, maybe not. Several days later, the administrator comes to the doctor: “You’ve got to get this man out of the ICU. It’s costing almost $800 per day, and he’s been there now for five days. What with everything else, we’ve already spent almost the whole payment we get for him.” The doctor thinks that the patient still desperately needs the specialized nursing available only in the ICU. The administrator overrules him. “There’s an area of judgment here,” he says. “We’ll just have to take a bit of a chance on this case.”
Or: the doctor decides that the patient is an excellent candidate for remedial heart surgery; a by-pass operation, he thinks, would probably prolong the man’s life considerably while relieving him of pain. But the man, after all, is elderly and the operation would involve a lengthy hospital stay. “Let’s try a more conservative treatment first,” the administrator says, “let’s give him some medication and wait and see.” Again, maybe the patient lives, maybe not.
Let us say that he lives and goes back to the regular ward in the hospital. He still feels very weak, and the doctor does not think he is anywhere near ready to be discharged. But the $5094 has long since been spent, and the administrator starts to wonder aloud: “Maybe this man could manage somehow at home. In any event, he’s eating us alive—get him out of here.” Maybe the patient will survive at home, maybe not.
Do you see the thrust of the system? If the hospital does relatively little for the patient, it makes money; if it provides an extensive range of services, it loses heavily. The best case from its viewpoint is for the patient to die right after admission: the hospital still gets the full fee. The worst case is for him to survive with complications and require a lengthy stay—which is why some hospitals are now refusing to admit patients they fear will linger on too long.
I do not mean to suggest that our hospitals are now merely shrugging and callously withholding urgently needed treatment from Medicare patients. Today’s hospitals and doctors do have integrity; most are continuing to do their very best for the patient. The point is that they have to do it now within the DRG constraints. The issue is not simply: treat the patient or let him die. The issue is: treat him how? At what cost? With what range of services, specialists, and equipment? With what degree of safety or of risk? This is the area where there is enormous room for alternatives in the quality of medical treatment. And this is the area that is now in the process of being slashed across the board for Medicare patients, the very people singled out by the liberals in the 1960’s as needing better medical care.
To revert to our nutrition analogy: it is as though the government socialized eating out, then paid restaurants in advance only what it computed as the average cost per meal. There would then be a powerful incentive for restaurants to cut corners in every imaginable way—to serve only the cheapest foods in the smallest amounts in the cheesiest settings. What do you think would happen to the nation’s eaters—and its chefs—under such a set-up? How long could the chefs preserve their dedication to preparing haute cuisine, when the restaurant-owners, in self-preservation, were forced to fight them at every step and to demand junk food instead? The same answer applies to our doctors today.
There is now a new and deadly pressure on the doctors, which continuously threatens the independence and integrity of their medical judgment: the pressure to cave in to utterly arbitrary, DRG economies, while blanking out the effects on the patient. In some places, hospitals are now offering special financial incentives to the physician who averages out at relatively low cost. For example, the hospital might subsidize such a doctor’s office rent or purchase new equipment for him. On the other hand, a doctor who insists on quality care for his Medicare patients and thereby drives up costs is likely to incur the hospital’s displeasure. In the extreme case, the doctor risks being denied staff privileges, which means cutting off his major source of livelihood. Thanks to DRGs, a new conflict is in the offing, just starting to take shape: the patient vs. the hospital. Or, to put it another way, the conflict is: doctors vs. hospitals—doctors fighting a rear-guard action to maintain standards against hospitals that are forced by the government to become cost-cutting ogres. How would you like to practice a profession in which half your mind is devoted to healing the patient, while the other half is trying to appease a hospital administrator who himself is trying to appease some official in Washington?
And remember that Medicare patients are not a small group. On the contrary, because of their age, they constitute a significant part of most doctors’ practice. Medicare patients now make up about 50% of all hospital admissions in the U.S.
The defenders of DRGs answer all criticisms by saying that costs simply must be cut. Even under complete capitalism, they say, doctors could not give unlimited treatment to every patient. This is true, but it ignores two crucial facts. 1) It is because of government programs that medical prices have soared so high and are now out of reach for masses of patients. This was not true in the days of private medicine. The average American a generation ago could afford quality, in medicine as in every other area of life, without courting bankruptcy. 2) Even if a patient could not afford it, at least, in the pre-welfare-state era, he was told the truth: as a rule, he was told about the treatment options available, and it was up to him, in consultation with his doctor, to weigh the various possibilities and decide how to cut costs. But under the present system, the hospital not only has to cut services drastically—it is to its interest to conceal this fact from the patient. If he or his family ever learns that the angiogram he is not going to have, or the heart surgery, would make all the difference to the outcome of his case, he would immediately protest violently, insist on the service, even threaten to launch a malpractice suit. The system is rigged to squeezing every drop of quality out of medical care, so long as the patient does not understand what is happening. The patient does not know medicine; he relies on the doctor’s integrity to tell him what services are available and necessary in his case—yet, increasingly, the hospitals must try to batter down that integrity. They must try to make the doctor keep silent and not tell the patient the full truth.
Under the new system, the patient is no longer a free man to be accorded dignity and respect, but a puppet on the dole, to be manipulated accordingly—while the doctor is transformed from a sovereign professional into a mere appendage and accessory, a helpless tool in a government-orchestrated campaign of shoddy quality and deception.
The government’s takeover of medical practice is not confined to public patients; it is starting to extend now into the private sector as well. This brings me to the HMOs, which are now mushrooming all over the country.
HMO means “health-maintenance organization.” It could also have been called BBM, for “bargain-basement medicine.” In this set-up, a group of doctors, perhaps with their own hospital, offers prepaid, all-inclusive medical care at a cheap rate. For a fixed payment in advance, a payment substantially less than a regular doctor would charge, the patient is guaranteed virtually complete coverage of his medical costs, no matter what they are. The principle here is exactly the same as that of the DRG system: if the patient’s costs exceed his payment, the HMO loses money on him; if not, it makes a profit..
Although HMOs are privately owned, the spread of these organizations is wholly caused by government. There were very few HMOs in the days of private medicine. As part of the government’s campaign to lower the cost of medical care, however, Washington has recently thrown its immense weight behind HMOs, even going so far as to advertise nationally on their behalf and to give them direct financial subsidies.
How do HMOs achieve their low rates? In essence, by the DRG method—the method of curtailing services. In this case, however, the cuts in quality are even more sweeping, inasmuch as the HMO embraces every aspect of medical care, and not merely hospital costs. For example, HMO doctors do not generally have personal patients, nor does the patient generally have a choice of doctors or even necessarily see the same one twice—that is too expensive. The patient sees whoever is on duty when he shows up; the doctor gives up the luxury of following a case from beginning to end. Nor does the doctor have much time to spend with a given patient—HMOs are generally understaffed to save money; typically, there are long waiting lines of patients. Further, the doctor must obtain prior authorization of any significant expenditure from a highly cost-conscious administrator. The doctor may detect a possible abdominal tumor and request a CAT scan—in effect, an exquisitely detailed, 3-D X-ray. But if the administrator says to him: “It costs a lot. I don’t think it’s necessary,” the doctor is helpless. Or he may find that the patient has an aneurysm, a weakening of an artery that is like a time bomb waiting to go off, and he may want to operate to remove it. But the administrator can reply: “These cases often go years without rupturing. Let’s wait a while.” Like the doctor under DRGs, the HMO doctor ultimately has to obey: he either keeps his costs within the dictated parameters, or he is out of work.
What kinds of doctors are willing or eager to practice medicine undei these conditions? In large part, they represent a new breed, new at leasl in quantity. There is a generation of utterly unambitious young doctors growing up today, especially conspicuous in the HMOs, doctors who are the exact opposite of the old-fashioned physician in private practice—doctors who want to escape the responsibility of independent thought and judgment, and who are prepared to abandon the prospect of a large income or a private practice in order to achieve this end. These doctors do not mind the forfeit of their professional autonomy to the HMO administrator. They do not object to practicing routine, cut-rate medicine with faceless patients on an assembly-line basis—so long as they themselves can escape blame for any bad results and cover their own tracks. These are the new bureaucratic doctors, the MDs with the mentality, and the fundamental indifference to their job, of the typical post-office clerk.
I hasten to add that there are better doctors in the HMOs (and that some HMOs are better than others). As a rule, however, the better doctors in these organizations are mercilessly exploited. Being conscientious, the better men put in longer hours than necessary, trying to make up for the chronic understaffmg. They do not give in meekly to arbitrary decrees on cost, but fight the administrator when they feel their own judgment is right. Increasingly, their professional life becomes a series of such fights, which makes them the heavies, hard to get along with and guilty of costing the HMO money—while their lesser colleagues capitulate to the system, do as they are told, and take things easy. Time after time, the better men step in to bail out such colleagues, struggling to correct their errors, clean up their messes, rescue their patients. At a certain point, however, the better doctors start to get fed up.
An HMO doctor in California, a qualified internist and a highly conscientious woman whom I know personally, told me the following story. “I was looking through a pile of cardiograms one day,” she said, “and I saw one that was clearly abnormal. I knew that the man should be taken by ambulance to the emergency room for re-testing and possible hospitalization. Then I thought: it’s late Friday afternoon, and it’s going to take an hour and a half, and I’m not being paid for the extra work, and who will know if I wait until Monday? I was tempted for a minute to drop the whole thing and go home, but then the remnants of my conscience made me get up wearily and telephone the patient. This sort of thing,” she concluded, “happens all the time and not just to me, and often the doctor does simply look the other way.” Do you see what happens under a system in which the doctor is penalized for his virtue or, at the least, is deprived of any incentive, spiritual or material, including pride in his judgment and payment for his work? Would you like your cardiogram to be in a pile on this new breed’s desk? Yours is next—all of ours are.
The cancer is growing inexorably. The debased standards inherent in government medicine are now spreading to the whole of medical practice in the United States. The new medicine is not restricted to Medicare patients or to HMO members; it is soon going to engulf private doctors as well, even when they see their own private, paying patients. There are many reasons for this. The most obvious is the pressure from the health-insurance companies, such as Blue Cross and Blue Shield. Hospitals now are charging higher rates to private patients in order to recoup their losses on Medicare cases. As a result, the private insurance companies are screaming, and demanding that a DRG-type system be imposed uniformly, on all patients. They want private insurance policies from now on to pay only according to arbitrary, preset DRG rates, just as Medicare does now, which would put the total of medicine in this country—all patients, all doctors, all ailments—into the same category as the heart-attack patient we discussed earlier. His fate would become everyone’s, and the standards of American medicine would simply collapse.
If this demand of the insurance companies surprises you, remember that there are no truly private health-insurance companies in the U.S. today. What we have, in essence, is a government-protected, government-regulated cartel in this field. And what the cartel wants is not more freedom, but more money by means of government favors, including stiffer government controls over medical costs.
The end of the Medicare road, in other words, is complete socialized medicine.
Now you can see the absurdity of the claim that state payment of medical bills will not affect the freedom of physicians or the quality of patient care. State funding necessarily affects and corrupts every private service. Communism, in fact, is essentially nothing more than state funding. The Soviets pretty much leave doctors, and everyone else, free to dream or fantasize within their own skulls; all the government does is fund everything, i.e., take over the physical means of every citizen’s existence. The enslavement of the country, and thus the collapse of all standards, follows as a matter of course.
Now let me backtrack for a minute. I have been maintaining that the cause of our soaring health-care costs is government funding of medical care. Many observers, however, claim that the cause is something different: the rapid advances in medical technology, such as CAT scanners or the latest, most sophisticated disease-detecting instruments, the magnetic resonance imaging or MRI machines. Some people, accordingly, want to limit such technology or even abolish it. Let me answer this objection briefly.
Technology by itself does not drive up costs; in fact, it generally reduces costs as it improves the quality of life. The normal pattern, as exemplified by the automobile and computer industries, is: a new invention is expensive at first, so that only a few can afford it. But inventors and businessmen persevere, aiming for the profits that come from a mass market. Eventually, they discover cheaper and better methods of production. Gradually, costs come down until the general population can afford to buy. No one is bankrupted, everyone gains.
What creates national bankruptcy is not technology, but technology injected into a field by government decree, apart from supply and demand. That is what is happening in medicine today. State-of-the-art medical treatment—including new inventions or procedures that are still prohibitively expensive, such as liver transplants and long-term kidney dialyses—is being financed by the government for the total population in the name of egalitarianism. The result is the unbelievable expenditures that are made routinely in our hospitals, far beyond most people’s capacity to afford. These expenditures are particularly evident in regard to the terminally ill, who almost always fall under the umbrella of some government-supported insurance program. It has been estimated that 1% of our GNP is now spent on the dying in their last weeks of life. Did you hear that? Or, looked at in another way: one-half of a man’s lifetime medical expenses occur now in the last six months of his life.
In a free society, you yourself would have to make a choice: do you want to defer consumption, cancel vacations, forgo pleasures year after year, so as to extend your life in the ICU by a few months at the end? If you do, no one would interfere under capitalism. You could hoard your cash and then have a glorious spree in the hospital as you die. I would not care to do this. It does not bother me that some billionaire can live months longer than I by using machinery that I cannot begin to afford. I would rather be able to make ends meet, enjoy my life, and die a bit sooner. But in a free society, you are not bound by my decision; each man makes and finances his own choice. The moral principle here is clear-cut: a man has a right to act to sustain his life, but no right to loot others in the process. If he cannot afford some science-fiction cure, he must learn to accept the facts of reality and make the best of it.
In fact, in a free society, the few who could afford costly discoveries would, by the normal mechanism, help bring the costs down. Gradually, more and more of us could afford more and more of the new technology, and there would be no health-cost crisis at all. Everyone would benefit, no one would be crushed. The terminally ill would not be robbing everyone else of his life, as is happening now, thanks to government intervention; the elderly would not be devouring the substance of the young.
Well—to return to my main theme—have I now covered, at least in essence, the ways in which government is wrecking the practice of medicine and tightening the noose around the doctors’ necks? I haVe barely scratched the surface. For example, I have not even mentioned the formal introduction of the principle of collectivism into medical practice—of committee-medicine as against individual judgment. This is exemplified by the flourishing PROs in our hospitals, the Professional Review Organizations, which act to oversee and strengthen the various DRG controls. PROs are committees of doctors and nurses established by the government to monitor the treatment of Medicare patients, and especially to cut its cost-committees with substantial power to enforce their arbitrary judgments on any dissenting doctor. These committees are the equivalent, in the Medicare system, of the HMO administrators, and have potentially the same kind of all-encompassing power to forbid hospital stays (along with the associated tests and surgical procedures), even when the admitting doctor thinks they are required.
Nor have I yet mentioned CONs, or Certificates of Need. Since the government regards anything new in the field of medicine as potentially expensive, a hospital today is prohibited from growing in any respect, whether we speak of more beds or new technology, unless the administrator can prove “need” to some official. Since “need” in this context is undefined and unprovable, the operative criterion is not “need” at all, but pull, political pull. Under this program, the government last year denied Sloan-Kettering, the famous New York cancer hospital, permission to purchase an MRI machine, because another New York hospital already had it. Later, the government backed down in the face of the resulting public uproar. But what about the hospitals that do not enjoy such fame or contacts, and that are inexplicably denied the right to acquire a new and crucial diagnostic tool? So far, the freeze on them is only partly effective. Doctors are still allowed to purchase new equipment for their own offices, which hospital patients now often use. But the government is fighting to close this loophole; it is on the verge of decreeing that private doctors in their own offices out of their own funds cannot purchase new equipment without a government certificate of “need.” Here again, by the way, you can see how your care will be affected, even if you are not a Medicare patient. If your doctor or hospital is not allowed to have the equipment, you cannot benefit from it either. It isn’t there. It doesn’t exist.
Nor have I mentioned the hundreds—yes, hundreds—of other government interventions in medicine. In the space of a year, state legislatures alone recently enacted almost 300 pieces of health-cost containment legislation. One hospital in New York now reports to 99 separate regulatory agencies.
And I have not yet even touched on what is perhaps the most demoralizing crisis in the field of medicine today, demoralizing to the doctors: the malpractice crisis. We must, however, pause on this one, because it illustrates dramatically, in yet another form, the lethal effects of government intervention in the field of medicine.
Medical malpractice suits have trebled since 1975. There are now about sixteen lawsuits for every hundred doctors. In addition, awards to plaintiffs today average around $330,000 and are steadily climbing. The effect of this situation on physicians is unspeakable. First, I have been told, there is fear, chronic fear, the terror of the next attorney’s letter in the mail. Then there is the agony of drawn-out legal harassment, including endless depositions and a protracted trial. There is the exhaustion of feeling that one lives in a malevolent universe, and that every patient is a potential enemy. Always, there is the looming specter: a career-destroying verdict. And whatever the verdict, win or lose, there is the fact that all of the doctors, innocent and guilty alike, are paying for it. They are paying for the exorbitant awards in the form of unbelievable insurance premiums—over $100,000 per year per physician in some places.
In response to this situation, doctors are forced to engage wholesale in what is called “defensive medicine,” i.e., the performing of unnecessary tests or procedures solely in order to build a legal record and thereby prevent the patient from suing later. For example, I heard about the case of a man falling and bumping his head slightly. Since there was no evidence of any head injury, there was no basis, in the doctor’s judgment, to order an expensive series of skull X-rays. But if he does not order it, he takes a chance: if, months or even years later, the man should develop mysterious headaches, the doctor might be sued; he might be charged retroactively with negligence, since he omitted a test that might have shown something that might have prevented the headaches. So the doctor has no choice; he has to order the tests to protect himself. By a conservative estimate, defensive medicine now accounts for about one-third of all health-care costs.
Since the medical profession did not suddenly turn evil or irresponsible in the last decade or so, we must ask what is the cause of the soaring lawsuits. The most immediately apparent answer lies in the law, which has now lost any pretense at rationality. The standards of liability are corrupt. Negligence, in any rational sense of the term, is no longer the legal standard. Today’s standard, in effect, demands of the doctor not responsible care, but omniscience and omnipotence.
For example, if a doctor prescribes a drug that is safe by every known test, and years later it is discovered to have side effects undreamed of at the time, the doctor can be sued. Was he negligent? No, merely non-omniscient.
If he treats a patient with less than the most expensive technology, whether the patient can afford it or not, he can be sued. “You open yourself to a malpractice suit,” says an attorney in the field, “if you even give the appearance of letting financial considerations conflict with good patient care.”1 Or: if a baby has a birth defect that can be ascribed to the trauma of labor, the obstetrician may be sued for not having done a Caesarian, even though there were no advance indications in favor of one—because, as one obstetrician puts it, people assume “that anything less [than perfection] is due to negligence.”2 This last statement actually reveals the operative principle of the law today, not of some crackpot left-wing radical, but of the law. the patient is entitled to have whatever he wishes, regardless of cost or means; it makes no difference what doctors know, or whether the money exists; the patient’s desire is an absolute, the doctor is a mere serf, expected to provide all comers with an undefined “perfect care” somehow.
Do you see where this idea comes from? It is the basic principle that underlies and gave birth to Medicare. “You the patient,” Washington said in the 1960s, “need do nothing to earn your medical care or your cures. From now on you need merely wish, and the all-powerful government will do the rest for you somehow.” Well, now we see the result. We see the rise of a generation of patients (and lawyers) who believe it, who expect treatment and cures as a matter of right, simply because they wish it, and who storm into court when their wish is frustrated.
The government not only inculcates such an attitude, but makes it seem financially feasible as well, because Washington has poured so much money into the field of medicine for so long. How else could anyone afford the defensive tests, or the inflated medical prices necessary to help pay for the incredible malpractice awards? They could not have been afforded in a free-market context. In the days of private medicine, there was no malpractice crisis; there was neither the public psychology nor the irresponsible funding that it requires. But now, thanks to government, there is both. And there is also a large enough corps of unscrupulous lawyers who are delighted to cash in on the disaster, lawyers who are eager to extort every penny they can from conscientious, bewildered, and in most cases utterly innocent doctors—while grabbing off huge contingency fees for themselves in the process.
The only solution to the malpractice crisis is a rational definition of “malpractice,” which would restrict the concept severely, to cases of demonstrable negligence or irresponsibility, within the context of objective definitions of these terms, taking into account the knowledge and the money available at the time. But this is impossible until the government gets its standards and its cash out of the medical business altogether.
Ladies and gentlemen, we are all kept alive by the work of man’s mind—the individual minds that still retain the autonomy necessary to think and to function. In medicine, above all, the mind must be left free. Medical treatment, as I have said, involves countless variables and options that must be taken into account, weighed, and summed up by the doctor’s mind and subconscious. Your life depends on the private, inner essence of the doctor’s function: it depends on the input that enters his brain, and on the processing such input receives from him.
What is being thrust now into the equation?—It is not only objective medical facts any longer. Today, in one form or another, the following also has to enter that brain: “The DRG administrator will raise hell if I operate, but the malpractice attorney will have a field day if I don’t—and my rival down the street, who heads the local PRO, favors a CAT scan in these cases, I can’t afford to antagonize him, but the CON boys disagree and they won’t authorize a CAT scanner for our hospital—and besides the PDA prohibits the drug I should be prescribing, even though it is widely used in Europe, and the IRS might not allow the patient a tax deduction for it, anyhow, and I can’t get a specialist’s advice because the latest Medicare rules prohibit a consultation with this diagnosis, and maybe I shouldn’t even take this patient, he’s so sick—after all, some doctors are manipulating their slate of patients, they accept only the healthiest ones, so their average costs are coming in lower than mine, and it looks bad for my staff privileges . . .” Etc. Would you like your case to be treated this way—by a doctor who takes into account your objective medical needs and the contradictory, unintelligible demands of 99 different government agencies and lawyer-squads? If you were a doctor, could you comply with all of it? Could you plan for or work around or deal with the unknowable? But how could you not? Those agencies and lawyer-squads are real, and they are rapidly gaining total power over you and your mind and your patients.
In this kind of nightmare world, if and when it takes hold fully, thought is helpless; no one can decide by rational means what to do. A doctor obeys the loudest authority; or he tries to sneak by unnoticed, bootlegging some good health-care occasionally; or he gives up and quits the field.
Now you can understand why the philosophy of Objectivism holds that mind and force are opposites—and why innovation always disappears in totalitarian countries—and why doctors and patients alike are going to perish under socialized medicine, if its invasion of this nation is not reversed.
Conservatives sometimes observe that government, by freezing medical fees, is destroying the doctors’ financial incentive to practice. This is true enough, but my point is different. With or without incentive, the doctors are being placed in a position where they literally cannot function—where they cannot think, judge, know what to do, or act on their conclusions. Increasingly, for a man who is conscientious, today’s government is making the practice of medicine impossible.
The doctors know it, and many have decided what to do about it. In preparation for this talk, I spoke to or heard from physicians around the country. I wanted to learn their view of the state of their profession. From New York to California, from Minnesota to Florida, the response was almost always the same: “I’m getting out of medicine.” “I can’t take it any more.” “I’m putting every cent I can into my pension plan. In five years, I’ll retire.”
Such is the reward our country is now offering to the doctors, in payment for their life-saving dedication, effort, and achievements.
As to talented newcomers rising to replace the men who quit, I want to point out that medical-school enrollments are now dropping. Bright students today, says the president of the Mount Sinai School of Medicine, are “discouraged by the perception of growing government regulation of medicine.”3 Note that it is bright students about whom he speaks. The other kind will always be in ample supply.
Any government program has beneficiaries, who fight to keep the program going. Who is benefiting from the destruction of the doctors? It is not the poor. A generation ago, the poor in this country received excellent care through private charity, comparatively much better care than they are going to get now, under the DRG and HMO approaches. The beneficiary is not the poor, but only one sub-group among them: those who do not want to admit that they are charity cases, those who want to pretend that they are entitled to medical handouts as a matter of right. In other words, the beneficiary is the dishonest poor, who want righteously to collect the unearned and consider it an affront even to have to say “Thank you.” And there is another beneficiary: the new 9-to-5, civil-servant doctor, the kind who once existed only on the fringes of medicine, but who now basks in the limelight of being a physician and healer, because his betters are being frozen out. And there is one more beneficiary: the medical bureaucrats, lobbyists, legislators, and the malpractice lawyers—in short, all the force-wielders now slithering out of their holes, gorging themselves on unearned jobs, money, fame and/or power, by virtue of having sunk their fangs into the body of the medical profession.
Altruism, as Ayn Rand has demonstrated, does not mean kindness or benevolence; it means that man is a sacrificial animal; it means that some men are to be sacrificed to others. America today is a textbook illustration of her point. The competent doctors, along with their self-supporting patients, are being sacrificed—to the parasites, the incompetents, and the brutes. This is how altruism always works. This is how it has to work, by its nature.
The doctors resent today’s situation passionately. Many of them are ready to quit, but not to fight for their field—at least, not to fight in the manner they would have to, if they were to have a chance of winning. In part, this is because the doctors are frightened; they sense that if they speak out too loudly, they may be subject to government reprisals. Above all, however, the doctors feel guilty. Their own professional motivation—the personal, selfish love of their field and of their mind’s ability to function—is noble, but they do not know it.
For ages they have had it pounded into them that it is wrong to have a personal motivation, wrong to enjoy the material rewards of their labor, wrong to assert their own individual rights. They have been told over and over that, no matter what their own desires, they should want to sacrifice themselves to society. And so they are torn now by a moral conflict and silenced by despair. They do not know what to say if they quit, or how to protest their enslavement. They do not know that selfishness, the rational selfishness they embody and practice, is the essence of virtue. They do not know that they are not servants of their patients, but, to quote Ayn Rand, “traders, like everyone else in a free society—and they should bear that title proudly, considering the crucial importance of the services they offer.”4 If the doctors could hear just this much and learn to speak out against their jailers, there would still be a chance; but only if they speak out as a matter of solemn justice, upholding a moral principle, the first moral principle: self-preservation.
Thereafter, in practical terms, they—and all of us—could advocate the only solution to today’s crisis: removing its primary cause; in other words, closing down Medicare. Reducing Medicare’s budget is not the answer—that will simply tighten the DRG noose. The program itself must be abolished. In principle, the method is simple: phase it out in stages. Let the government continue to pay, on a sliding scale, for those who are already too old to save for their final years; but give clear notice to the younger generations that there is a cut-off age, and that they must begin now to make their own provision for their later medical costs.
Is there still time for such a step? The most I can answer is: in ten years, there won’t be—that is how fast things are moving. In ten years, perhaps even in five, our medical system will have been dismantled. The best doctors will have mostly retired or gone on strike, and the government will be so entrenched in the field that nothing will get rid of it.
If you are my age, you may sneak by with the rest of your lifespan, counting on the remnants of private medicine that still exist. But if you are like many of the faces I see out there—in your teens, twenties, thirties—then God help you! To you, I want to conclude by saying: find out what is going on in this field—don’t take my word for it—and then act, let people know the situation, in whatever way is open to you. In particular, talk to your doctor. If you agree with the Declaration of Independence, tell him that he, too, comes under it; that he, too, is a human being with a right to life; and that you want to help protect his freedom, and his income, on purely selfish grounds.
If you are looking for a crusade, there is none that is more idealistic or more practical. This one is devoted to protecting some of the greatest creators in the history of this country. And it is also, literally, a matter of life and death—your life, and that of anyone you love. Don’t let it go without a fight.
“Medicine: The Death of a Profession” Copyright (c) 1985 Leonard Peikoff Reprinted from The Objectivist Forum (April and June 1985) Published by the Ayn Rand Institute
Arthur R. Chenen, “Prospective Payment Can Put You in Court,” Medical Economics, July 9, 1984. ↩
Allan Rosenfield, quoted in Susan Squire, “The Doctors’ Dilemma,” New York, March 18, 1985. ↩
James F. Glenn, quoted in “Professional Schools’ Enrollment Off,” The New York Times, Feb. 10, 1985. ↩
“How Not to Fight Against Socialized Medicine,” The Objectivist Newsletter, March 1963. ↩