I continue my debate with Graham. If you read his post, he actually concedes most of my points - Graham responds #2
I will address two points. The first is perspective. I always take the physician perspective rather than the public health perspective. As a physician, I believe that my duty extends solely to my patients. Public health and public policy are not my concerns. I must provide the best care that I can to my patients. If we do not have enough physicians, then let the policy experts work out that problem. I am happy to make suggestions, but daily that is not my concern.
So I reject the public policy arguments against retainer medicine because of my perspective. I focus on understanding the growing success of the movement. If we understand the success, then we learn truths about the flaws of standard practice. While money contributes, I would argue that the main motivation comes from the misery of trying to see patients every 15 minutes when you really need 30 minutes. One can only dance that dance for a defined period until mental and emotional exhaustion occurs.
The second issue is the phrase Social justice.
Social justice refers to the concept of a society in which justice is achieved in every aspect of society, rather than merely the administration of law. The term can be amorphous and refer to sometimes self-contradictory values of justice. It is generally thought of as a society which affords individuals and groups fair treatment and a just share of the benefits of society. (Different proponents of social justice have developed different interpretations of what constitutes fair treatment and a just share.) It can also refer to the distribution of advantages and disadvantages within a society.
Social justice is both a philosophical problem and an important issue in politics, religion and civil society. Most individuals wish to live in a just society, but different political ideologies have different conceptions of what a ‘just society’ actually is. The term “social justice” is often employed by the political left to describe a society with a greater degree of economic egalitarianism, which may be achieved through progressive taxation, income redistribution, or property redistribution. The right wing also uses the term social justice, but generally believes that a just society is best achieved through the operation of a free market, which they believe provides equality of opportunity and promotes philanthropy and charity. Both right and left tend to agree on the importance of rule of law, human rights, and some form of a welfare safety net (though the left supports this latter element to a greater extent than the right).
Carrying for individual patients does not promote social justice, nor does starting a retainer practice negatively impact social justice. Physicians may purposely decide that they want to serve the under-served. That decision must come from ones individual philosophy. Social justice can only come from public policy. I do believe that the existence of retainer medicine is completely tangential to social justice.
We will likely always have levels of medical care, just as we have levels of food and shelter. Even in so-called communistic societies, everyone was not provided the same service. George Orwell probably said it best - “All animals are created equal, but some animals are more equal than others.” Many would argue that trying to provide the same level of food, shelter and medical care to all would lower the standard of care for all.
I urge all readers to look at the retainer movement carefully. Try to understand the reasons for its increasing success. Perhaps these entrepreneurs are simply providing patients what they desire. If that is true, we need policy wonks who can use this model to improve health care for all.
Living in the Deep South, we often say, “if it ain’t broke, don’t fix it.” Our current health care system is broken. Retainer medicine is one experiment aiming to fix it. Rather than attack it on moral grounds, learn from its success. Perhaps those lessons can help all patients in the future.
Thanks greatly to Graham for his careful and thoughtful comments. We always learn more when we debate serious issues. His commentary has helpful me examine my philosophical approach to this issue.
ninguem
December 28th, 2007 / 10:56 am
Why is one economic model “ethical” and another is not?
It is “unethical” to run a retainer practice because someone may not be able to afford the retainer, or chooses not to pay the retainer, spending the funds on something else (cigarettes)? Why, then, is fee-for-service medicine “ethical”? Someone may not receive healthcare because he cannot pay the fee, or chooses to spend the funds on something else (cigarettes)?
Like your Hillel Talmud Shabbath 31a, on the side, all the rest is commentary. Is it ethical for a doctor to expect compensation for services rendered? If yes, the rest is commentary. Some may choose fee-for-service, some employed models, some retainer practices. Assuming services paid for are actually delivered. They are all ethical, or none are ethical.