medical discourse

A follow-up on one element of this post: It would be uncharitable and just plain wrong to conclude that doctors and other health-care professionals lack compassion and want to make you suffer. Nevertheless, what Ivan Illich wrote in Medical Nemesis (1975) was true then and is true now: “Modern medicine is a negation of health. It isn’t organised to serve human health, but only itself, as an institution.” The system works by purposes that the workers within the system may not share — but they are compelled to serve those purposes anyway.

I think the first thing to understand about the American health-care system is this: some people lose money from illness, and some people make money from illness. Some people pay, and some people get paid. This doesn’t mean that the people who get paid are motivated solely or even primarily by money, though some of them surely are; this doesn’t mean that those who pay always resent having to pay, though some of them surely do. What it means is that there is on this one significant point an opposition of interests between the two parties; and that opposition manifests itself in a thousand ways. You see it when sick people don’t go to the doctor because they don’t want to, or can’t, pay for the services that would be rendered there; you see it when doctors advocate for unnecessary procedures that line their pockets, or prescribe drugs because they have a lucrative relationship with particular drug companies; you see it when money-making procedures are deemed necessary while the poor get dramatically sub-par health care or none at all.

Again: I don’t think there are many doctors who consciously make medical decisions based on their lust for money. But I do think there are a great many doctors who go along with the incentives established by the system, without thinking about it too much or at all, because on some level they know that thinking about it could well lead to their losing money.

And this opposition of interests cannot be eliminated; in the current system — where profit is God even for supposedly nonprofit hospital systems — it cannot even be diminished.

But our discourse about medicine and health care is radically skewed towards the doctors and other health-care professionals. The voices of the patients — those who suffer, and those who pay — are rarely heard. This is the importance of books like Ross Douthat’s The Deep Places — and there ought to be a lot more of them. It’s not that we don’t have books and essays by people who have been abused or abandoned by the medical system — there are plenty of them — but they get tragically little attention, largely, I think, because journalists think of themselves as belonging to the same “Professional” category as doctors and don’t want to be class traitors.

It’s good to have books by doctors who see the evils of the system and fight back against it — people like Oliver Sacks, about whom I have an essay coming out soon from The New Atlantis, and Victoria Sweet — but we really do need to hear more from patients, and especially patients the system doesn’t serve. Because the incentive structures of American health care ensure that, without major changes, things will get worse before they get better.

This is a cause worth fighting for, but it will be hard to get enough people on board if we don’t hear more from those most affected.