AGAINST IDEOLOGY.

Solving health-care problems

For the past two years I have been directing an international research project at the Hastings Center on "Medicine and the Market." My aim has been to see how, in different cultural and political settings, the relatively recent turn to market ideas and tactics has affected health- care systems. Do market strategies help to control costs? What do they do to equity of access to health care? What is the impact on the doctor-patient relationship and on physician integrity? I could go on at inordinate length about what I have found so far-in general, market strategies don't necessarily control costs well, equity is almost never helped, and the evidence is mixed about the effect on the doctor- patient relationship-but I want instead to talk about the ethical problem of trying to carry out a study of this kind.

Good ethical analysis, I believe, requires three skills and one key virtue. One of the skills is an understanding and wise deployment of ethical arguments and traditions, religious and philosophical. Another is a lively awareness of the social and cultural setting of moral problems and dilemmas. Still another is self-understanding, by which I mean an ability to see and to assess one's emotional responses to problems and to spot one's biases and predilections. The key virtue is that of honesty: a willingness to take on the hard problems fairly and squarely and to be always self-critical. Ideology also plays a crucial part in the way people respond to many moral problems; that is, the way they see the world and position issues over against their own social and political agendas. Hence, the skills and virtues I mentioned may first of all have to be deployed to deal with those ideologies.

For a large number of people, "the market" has a quasi-religious status. It is not just a way of managing financial relationships but the key to a free and decent society. Government is the enemy, stifling commerce, promoting the dead hand of bureaucracy, and interfering with personal liberty. A strong market is the antidote. For another group, also large, the market is a symbol of uncontrolled self-interest and injustice and in practice a recipe for a cruel social order. A participatory democratic order, a strong role for government in promoting the common well-being of society, and a vigorous concern for the poor and dispossessed are social necessities. The commodification of life, which the market advances, is the greatest enemy.

The trouble with these competing ideologies is that they have different human goods as their focus, different notions of social evil, and a different attitude toward the available evidence about their value. Market proponents tend to dismiss the accusation that it promotes a dog-eat-dog society; they argue for the necessity of a strong moral order to undergird the market-and it was Adam Smith who first said that. Yes, market values can be a corrosive acid for moral values, but not necessarily. Strong religious values offer an important line of defense against market corruption. Market opponents do not take the rise and fall of communism as the ultimate story about the place of government and planned economies. Communism was terrible, but it was an aberration, nothing more than a recipe for a police state dressed up in the rhetoric of equality. The welfare states of Western Europe offer better, more democratic models.

So the arguments go, back and forth. An ideologue may be defined as someone who believes that the issues have once and for all been settled, that there is nothing good to be said for the other side. That is precisely what makes a project on medicine and the market difficult to manage. First of all, it is true, as market zealots argue, that the market in its purest form has never been tried; there are no governments that have abandoned all health programs, turning them over to the private sector. Governments have, so to speak, infected all markets by their regulatory interference, not giving them a decent chance to show what they can do. It is also true, as strong-government proponents often contend, that market practices and attitudes can subvert good government. For-profit HMOs, for instance, are likely to provide poorer care for the elderly under Medicare than nonprofit organizations.

There is a conventional answer to all this coming from health-care economists. It is that no country could or should have a purely market approach to the care of sick people. Not everyone will be able to pay for health care and every government will be forced to do something about that. The real question is not market vs. government, but getting the right balance, allowing play to the market but maintaining a good government safety net for those unable to pay for health care.

Well, it is always hard to argue against "balanced" approaches to anything, and I will not do so here. I have no doubt that that particular strategy will carry the day in most countries, though of course with different balances in different places. What I think important is to treat the problem as, essentially, a matter of practical judgment, trying as much as possible to put aside the kind of faith and singlemindedness that nourishes ideologies and ideologues. Almost every country in the world is now having a problem paying for health care. Experiments and reforms abound. That is a good thing. No one can really say at this point how best to run and fund health-care systems in the long run. The Right has turned the market into a holy grail, good for whatever ails us, from prisons to health-care systems. That's silly, and dangerous. The Left hasn't sufficiently noticed that welfare-oriented governments have not yet found a way to run universal health-care systems that effectively cope with aging societies, constant and expensive technological innovation, and rising public demand. Most look to the market, at least a little bit, for some help.

The main moral I draw is this: Be slow to make large and sweeping moral judgments about medicine and the market. Instead, watch the experiments carefully; be simultaneously hopeful, encouraging, and skeptical about reform schemes; take your time. I don't believe they will work, but then nothing else is working very well either. So, as Chairman Mao once said, "Let a thousand flowers bloom"-but it could have been Adam Smith."