AiA Library: Medical Practice, Policy, Regulation

Medical Practice, Policy, and Regulation
The Moral Physician
Thomas S. Szasz, M.D.
Dr. Szasz asks the question: "What is the moral mandate of medicine?"

Physician Licensure: A New Approach to Examining the Role of Professional Interests
"For years, economists have debated the extent to which organized medicine has benefited from medical licensing restrictions. This debate has b een hampered by the lack of a viable alternative hypothesis. This pap er provides an alternative hypothesis and suggests an empirical test which focuses on the relationship between licensure restrictions and the level of consumption of physician services across states. The evi dence suggests that in the mid-1960s the interests of organized medic ine dominated those of consumers in influencing the medical regulator y supply process."
Shirley V. Svorny, Economic Inquiry, 1987, vol. 25, issue 3, pages 497-509

Should We Reconsider Licensing Physicians?
"This article focuses on the role of medical licensure in motivating physician service quality. It characterizes recent changes in health care markets as reducing the positive contribution of licensure to social welfare. These changes include increased hospital and health maintenance organization (HMO) liability, incentives to shift to for-profit provision of care, increased use of brand names, direct employment of physicians, and the establishment of national data banks that keep records of physicians' past performance Also, the article argues that recent and expected pressures on physician earnings reduce the incentive effects of existing state licensing arrangements."
Shirley V. Svorny, Contemporary Economic Policy, 1992, vol. 10, issue 1, pages 31-38

The Consequences of Managed Competition
"Under managed competition the primary care physician takes complete charge of the patient’s health care. The primary care physician is encouraged, and often financially rewarded, to limit and reduce the number of patients he refers to a medical or surgical specialist. . . Under managed competition, a female patient, for example, loses her prerogative to see a gynecologist unless she first obtains the permission of her primary care physician to make such a visit.. . The limiting of referrals, a basic concept of managed health care, is in direct conflict with the structure of American medical education and the medical profession. Such limits can cause primary care physicians general practitioners to prescribe care at levels that exceed their knowledge and training. When this occurs, the patient runs the risk of receiving improper care."
Vincent W. Cangello, Ideas on Liberty, Nov. 1993.

The Freeway to Serfdom
"In Canada, you don’t have to pay to get medical care. In fact, you are not allowed to pay. Once the global budget is reached in Canada, that’s it. The on-ramps are closed. It doesn’t matter if you have money. Hospital beds are empty for lack of money to pay nurses, and CT scanners sit idle all night for lack of money to pay a technician. But if some people are allowed to pay, Canadians fear that some people might get better care than others."
Jane M. Orient, Ideas on Liberty, Nov 1993.

Weird Science: How Fat and Salt Became Bad
Does eating a lot of salt and fat kill people? "Of course," most Americans would respond. Many would even think salt and fat are almost as bad as tobacco. After all, isn't this what we've been told for years by the health-care professionals who set government dietary guidelines?...However, it turns out that the federal guidelines recommending restricted consumption of these substances are a perfect example of how the uncertainties of science get transformed into hard-headed government policies. The story of how salt and fat became bad has recently been revealed in a couple of superb articles by Science magazine correspondent Gary Taubes. Taubes details exactly how, why, and when the misperceptions passed into policy; his pieces are required reading for anyone interested in the vagaries of policy making.
Ronald Bailey, Reasononline, May 2, 2001.
See: A DASH of Data in the Salt Debate, Gary Taubes, Science 2000 May 26; 288: 1319.

The Therapeutic State: The Tyranny of Pharmacracy
Joining the traditional rationalizations for state coercion — "God's will," "the consent of the governed," and "social justice" — comes a fourth: "coercion as treatment." Unlike theocracy, democracy, and socialism, however, pharmacracy has met little opposition.
Thomas S. Szasz, M.D., The Independent Review, Spring 2001

Socialized Health-Care Nightmare
"After seventy years of socialist economizing, 57 percent of all Russian hospitals do not have running hot water, while 36 percent of hospitals located in rural areas of Russia do not have water or sewage."
Yuri N. Maltsev and Louise Omdahl, Ideas on Liberty, November 1994

Have Doctors Forsaken Their Ethics?
"One conflict that must be resolved is the choice between remaining committed to the "Hippocratic Ethic" or embracing what is called the "Veterinary Ethic." The Hippocratic Ethic holds that a physician's ultimate responsibility is to the patient. Consequently, all advice given regarding therapy is based upon what the physician perceives to be in the patient's best interest. The Veterinary Ethic holds that the physician's ultimate responsibility is to the payer, and that advice is therefore based upon what the physician perceives to be in the payer's best interest. An example of this is when the veterinarian recommends to an owner that an animal be "put to sleep" rather than undergo costly treatment."
Jeffrey A. Singer, Ideas on Liberty, April 1995

The Health Risks of Censorship: FDA's Advertising Regulations Cost Lives!
"Each year, 700,000 Americans die of heart-related disease and 50,000 die from colon cancer...But thanks to the FDA, many don't know that aspirin could help. Most consumers are unaware that some drugs used for one ailment may be quite effective for others. And the FDA forbids manufacturers from advertising the heart attack benefit of regular aspirin use. For the thousands at risk for heart attack, the FDA's gag order is a prescription for disaster."
Paul H. Rubin, The Independent Institute, Nov 1995

We're All Sick, and Government Must Heal Us
"In recent decades a portentous cultural change has been gathering momentum in the United States, giving rise to dangerous social and governmental developments."
Robert Higgs, The Independent Review, Spring 1999

You Get What You Pay For: Result-Based Compensation for Health Care
This article proposes greatly increased use in the health care sector of incentive arrangements that tie providers' compensation to the outcomes they deliver for patients.
David A. Hyman and Charles Silver, The Independent Institute, Working Paper No. 32.

Prices, Markets, and the Pharmaceutical Revolution (pdf)
Although pharmaceutical costs have aroused controversy for decades, debate has intensified over the past year. Proposals to add a drug benefit to Medicare are being floated, which raises the specter of price controls. This book explains why efforts to control drug prices through political means are deeply misconceived and could thwart today’s dramatic improvements in health.
John E. Calfee, American Enterprise Institute, 2000

Making Sense of Drug Prices (pdf)
How to make drugs more affordable without stifling beneficial innovation and competition.
Patricia M. Danzon, Regulation, Vol. 23, No. 1, March 2000-February 2001

Doctor's Orders: Parents battle medical authorities for control of their children
"The conflict between a parent's wishes and the state's notions of how to protect children's health has traditionally been fought on religious grounds, often through cases involving Christian Science or other sects that reject standard medical care. But in a largely secular contemporary America, such conflicts increasingly go beyond religion. Parents caught up in heated scientific and ethical debates are finding themselves threatened with loss of their children, or what amounts to nearly the same thing, loss of legal control of their children. Fortunately, in a world of increasing access to information-and one in which authorities of all sorts hold less clout than they used to-many parents are fighting back."
Brian Doherty, Reason, Feb 2001

Perspectives on the Pharmaceutical Industry (pdf)
Americans spend more per capita on alcohol, tobacco, and entertainment combined than on pharmaceuticals.
Uwe E. Reinhardt, Health Affairs, Vol. 20, No. 5, September/October 2001

Socialized Medicine Is the Problem
Some people think there is something special about medical care. There is not. Yes, if we do not avail ourselves of it, we will be in dire straits. But no less can be said for food, clothing, shelter, energy, transportation—you name it. And economic law, just as in the case of chemistry or physics, is no respecter of how important an industry is to human well-being; it works just the same in medical services as for paper clips or rubber bands. Impose artificially lower prices in a market—let alone virtually zero prices as in medicine—and you guarantee a shortage."
Walter Block, Ideas on Liberty, Dec 2001

Rationing Health Care: Price Controls Are Hazardous to Our Health
"The tragic effects of price-controls, whether direct caps on medications and health services or budgetary caps on providers and health service institutions, can be seen in every country that has tried them. Indeed, the whole concept of budgetary caps , is particularly worrisome, as foreign examples of such a price control-based policy clearly show."
Simon Rottenberg and David J. Theroux, The Independent Institute

Organ transplants: who should decide?
Walter Williams
"An organ market would eliminate the arbitrariness of doctors and bureaucrats sitting around like gods, deciding who will die and who will live.

Does Physician Licensing Serve a Useful Purpose?
The presumption underlying state licensing of physicians is that the state offers consumers needed protection through its efforts toward monitoring physician competence. If this was ever true, a strong argument can be made that it is no longer the case. With the growth of managed care, a new set of eyes has entered the health care arena. Armed with software that tracks physician performance, providers are able to use their in-house expertise to evaluate and assess physician performance.
Shirley V. Svorny, The Independent Institute, July 10, 2000

Drug Price Controls: A "Cure" Worse Than the Disease
"The U.S. pharmaceutical industry is an unfortunate victim of its own success. Spending on drugs has doubled in the past decade but not because of price increases. Spending has doubled because revolutionary new drugs have been created for the treatment of heart disease, diabetes, osteoporosis, arthritis, depression, obesity, blood pressure and other illnesses. In other words, we're spending more on drugs because we're using drugs more."
Alex Tabarrok, Patriot News (PA), May 22, 2000

A Free Market in Kidneys: Efficient and Equitable
"The National Organ Transplant Act of 1984 prohibits the purchase and sale of kidneys in the United States even though thousands of Americans die or suffer each year because of the ban. A free market in kidneys, along with third-party payers, would encourage kidney donations and give rise to market competition that would increase the quality of transplants and the transplant process."
Barnet et al. The Independent Review, Winter 2001

Nursing Is Not Just a Numbers Game
The idea that government can tell hospital administrators how many nurses per patient they should have makes about as much sense as telling auto manufacturers how much steel should go in their cars. The right amount depends on the value of steel in production and its relative price. Both things change over time, and mandated production methods limit flexibility, preclude efficient production and result in fewer desired outcomes.
Shirley V. Svorny, Los Angeles Times, Jan 25, 2002

Under the Microscope: Inverview with Surgeon Atul Gawande
"Let me put it this way: it's the question of whether we need to believe in the myth of the infallible doctor in order to be able to put ourselves in his hands. I think a lot of doctors have certainly thought so for a long time. But we've reached a point where that myth seems to do more harm than good. It means that patients aren't asking questions, aren't getting second opinions, and that doctors are sometimes providing bad care without being questioned about it."
Atlantic Unbound, May 1, 2002

Scanning for Health? "Ignorance is bliss," say some doctors
"Despite decades of progress in empowering patients and breaking down medical paternalism, the impulse to limit patient's choices is still all too strong."
Ronald Bailey, Reason, May 2002

Medical Technology and the State
"Normally, technological advances are a benefit to producers and consumers alike. Government financing, however, introduces a third party—the taxpayer—who is bled dry. State governments have attempted to restrict health-care technology by requiring providers to obtain licenses called “Certificates of Need” (CON) from state officials in order to purchase new equipment. CONs supposedly reduce government expenditures by making medical technology less available, just as socialized medicine does in Canada. This approach to cutting medical costs frequently leads to political scandals and long waits. Most important, it does nothing to redirect entrepreneurs toward reducing costs."
Gary M. Pecquet, Ideas on Liberty, May 2002

No news is bad news: It's time to open up the FDA
"In 1999, doctors at the University of Pennsylvania injected 18-year-old Jesse Gelsinger with an experimental gene therapy as part of an FDA-approved clinical trial. Four days later, he died...Patient advocacy groups protested. The experimental gene therapy that killed him was aimed at correcting the rare disorder disabling his liver. But the trial promised nothing in the way of a cure for Jesse Gelsinger—its goal was to test the safety of the treatment for use in infants. Had Gelsinger or his family been given informed consent to what turned out to be a deadly human experiment? Were they told all the FDA knew about the risks and benefits of the treatment?...The answer is no. And shockingly, there is nothing unusual about that. Every day, information is routinely withheld from thousands of patients participating in clinical trials."
Scott Gottlieb, The American Spectator, May/June 2002

The Fear of Litigation Study: The Impact on Medicine (summary)
"Concerns about liability are influencing medical decision-making on many levels. From the increased ordering of tests, medications, referrals, and procedures to increased paperwork and reluctance to offer off-duty medical assistance, the impact of the fear of litigation is far-reaching and profound." (full report, pdf 346k)
HarrisInteractive, April 2002.

Drugs and me -- and you
"I, for one, want to thank America's pharmaceutical companies for those expensive drugs. They have kept me alive for 21 years after I could have died, and would have, through most of our history. They have kept me functioning actively and out of the hospital and off dialysis. They have spared me broken bones and kept me breathing. And now, as I head toward another kidney transplant, expensive drugs will give me a renewed life once again -- an absolutely normal life, making a living, taking care of my kids. Drugs will be more expensive this time around, and a good thing, too. Improved immunosuppressants have boosted the success rate for live related donor kidney transplants from about 65 percent, at the time of my first transplant, to better than 90 percent today."
Lawrence Harrison, TheAmericanProwler.org, June 11, 2002.

A Model for Medical Tyranny
"In the wake of September 11, every state has been asked to enact a law providing for unprecedented, comprehensive health surveillance and medical martial law. . . The Model State Emergency Health Powers Act, proposed by the Centers for Disease Control and Prevention (CDC), would provide a state's governor with sole discretion to declare a public-health emergency. Once the emergency was declared, public-health officials would assume police powers, the militia would be mobilized, and the legislature would be prohibited from intervening for 60 days. Any new orders and rules issued by the governor would have the full force of law. Existing laws and individual rights could be suspended."
Twila Brase, Ideas on Liberty, Aug. 2002

Free-Market Medicine
"The health-care system in the United States is beset by problems. After years of feeling shortchanged by managed care, doctors and hospitals are demanding and getting greater compensation; the elderly (under Medicare) have no prescription coverage; and many people find health insurance of any kind unaffordable. Managed care, which was hailed as the answer to spiraling costs, is under legislative and legal assault, while health-care costs are rising at double-digit rates. Proposed solutions range from a Canadian-style single-payer system to medical savings accounts to staying the course with managed care."
Larry Van Heerden, Ideas on Liberty, Aug 2002

The Peril to our Privacy
"If the Bush administration has its way, beginning in April 2003 individuals' personal health information-including genetic information-will be shared with data-processing companies, insurance companies, doctors, hospitals, researchers, and others without their consent. This is a major shift from today's standard whereby patients give their consent before their medical records are shared with third parties. The administration proposes to eliminate the current standard in order to make processing medical claims more efficient. If the changes are adopted, every American will have effectively lost any ability to maintain a confidential doctor-patient relationship."
Sue A. Blevins, Ideas on Liberty, Oct. 2002

Patent Absurdity: Ending a drug company scam
"But in recent years, major pharmaceutical companies have gotten greedy. Instead of being satisfied with their 20-year monopolies on new drugs, they have tried to prevent competing manufacturers from using their recipes to make cheaper versions of their drugs. . . A particularly egregious example of how this works is the ploy used by the Anglo-Swedish pharmaceutical company AstraZeneca to thwart the introduction of generic versions of its blockbuster anti-heartburn medication Prilosec, the patent for which expired a year ago. AstraZeneca, attempting to extend its monopoly, filed a new patent claim describing how Prilosec could be sprinkled on applesauce for use by patients who have trouble swallowing pills. Under Food and Drug Administration (FDA) rules, this meant that would-be generic competitors would have to prove that their versions would behave the same way when sprinkled on applesauce. Overcoming this hurdle will require more testing and cause more delays, preventing patients who can swallow pills from getting cheaper drugs.
Ronald Bailey, ReasonOnline, Oct 23, 2002

Review of Thomas Szasz's Liberation by Oppression by Robert A. Baker, professor emeritus of psychology, University of Kentucky.

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American Iatrogenic Association Library Information that improves understanding of medical error, philosphy, and practice

American Iatrogenic Association Library
Information that improves understanding of medical error, philosphy, and practice