Ronen Avraham’s Idiot Idea

Here, one Ronen Avraham describes an Obama administration plan to indemnify doctors against malpractice claims when they follow published guidelines, set by nonprofit medical boards and insurance companies.

This itself continues to change the doctor from an independent professional into an overpaid mechanic, but the money boys would prefer that we all work like machines.

After they destroy the autonomy of teachers, doctors may be next.

Avraham wants to privatize the guidelines. Guidelines would be published by a new form of company. The doctor would pick and choose his guidelines from a particular company. If he follows the guidelines, he is indemnified (protected from a malpractice lawsuit).

But if the guidelines are found to be flawed, then the company is sued or in some way beaten to death with a wet noodle.

The main problem, so obvious as to make one question the competence of Ronen Avraham, the author of this article, is in his sentence “However, the private regulators themselves would be liable if their guidelines were found to deviate from optimal care.”

Excuse me, but who would “find” the guidelines deviant?

There’s a whole set of useful saws one learned long ago in Latin, but nobody studies Latin any more, not even doctors. One is,
quis custodiet ipsos custodes. Who shall guard the guardians?

Avraham’s phrase “were found to deviate” is a classic example of using the passive voice to conceal agency and responsibility. Mr. Avraham’s “market solution” will either create a non-market bureaucracy, the “finders of the deviance from optimal care”, or it will allow the guideline publishers to save money and increase profits by making the guidelines up.

I can see it now, based on our experience of phony marketization since Reagan.

Every day, underpaid medical students will author the guidelines by surfing the Web once they get tired of procrastinating on Facebook.

The guidelines will suck on a random basis.

Doctors will follow the deviant guidelines even when they need to throw them out to save a life, especially when the life in question is on Medicare.

The guideline publishers will (like “objective” sources of financial information such as Moody’s and Standard and Poor’s) rapidly become effective monopolies since there’s no way they can compete on quality. They will all publish readable guidelines at a low cost using computerized methods. But by definition, and in the best case, the doctor will not know which are the best guidelines from the standard of patient care because of the custodiet problem.

He might select the easiest guidelines.

The ideological free market answer to custodiet is a sort of network. In it, everybody watches everybody else, for profit or for a wage.

This “network legitimacy” is like sausage. You don’t want to see it being manufactured. It bears a strange resemblance to the STASI surveillance of East Germany and it is guaranteed to contain strange indirect loops of arbitrary length (a watches b, c watches a, d watches c, and b watches c).

Doctors were given a monopoly over and above the free market because of the importance of human life. Until the malpractice crisis of the 1970s, created by the sense of entitlement of the 1960s, it was assumed that the doctor could be the final decision maker. This worked in the main because the old-fashioned doctors actually believed that they had a duty over and above billing the patient.

But then the very sense of me-first entitlement of the 1960s created the new model doctor, such as the clown at Evanston Hospital who told me to keep smoking so he could put his son through medical school: men without bones, men without depth, men without compassion, who viewed themselves as automata driven by fees.

The reaction to the abuses of these doctors was the increase in malpractice suits against the charlatans, for which honest doctors started to pay in the form of malpractice insurance. Subsequently a number of social mechanisms have been found to eliminate the short-term crisis, all of which have damaged the quality of care, except, of course, for the wealthy.

Networks cannot control greed: this was demonstrated in the financial crisis of 2008. They just move the problem around.

Following procedures is a very good idea. It has made air travel safe, according to aviation writer William Langieweische. Doctors and nurses have increasingly used checklists to make sure they do not miss a step in patient care.

Ultimately, however, the procedures must come from some place outside self-interest. Avraham seems to me to be one of those cynical ideologists who believe that we all act all the time to maximize returns.

This just isn’t true. I’ve spent forty years trying to have fun and do my duty as a father. Capitalism becomes daemonic when it commands us to always seek profit even when deciding on patient care. It denies the existence of a truth-seeking “civil society”, and in this denial it destroys this society, transforming its members who aren’t financially mega-successful into objects…addicts, debtors, and ne’er do wells.

A doctor like my father, who was of course anxious to use best practice at all times and who studied for and passed Illinois tests to re-enter medical practice at 65, becomes a sucker and a Willy Loman at best, or a rebel at worst when he resisted the definition of death as brain death.

Thanks to this perverse and ideological worship of the “free market”, we will all be more and more enslaved to a shrinking class of thugs with advanced degrees.


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