Chapter Eleven. The Ethics of Compulsory Medicine

Diseases of the soul are more dangerous and more numerous than those of the body. (Morbi perniciosiores pluresque sunt animi quam corporis.) Cicero~ Tusculanarum Disputationum. eHA PTER E L Hi V iJ!J N The Ethics of Compulsory Medicine SOFAR, the scientific a~d ethi cal standards of medical practice have not suffered as appre ciably in France and Belgium as they have under compul sory systems in other countries. But the threat of deteriora tion and corruption is hanging over all of them. PROBING THE The officials of every health scheme grow ABUSES indignant if the soundness of its operations is questioned. Some corruption is generally admitted. Is there a human institution that is free of mis chief?! On the other hand, every country which I have visited is buzzing with stories about the waste of sickness funds and functions. Are they scattered cases? Is it irresponsible gossip? No statistical evidence is available to gauge the amount or degree of "criminality"-except from Russia. Soviet papers reiterated in the middle 1930's that as many as 36 per cent of all sickness-certificateswere fraudulent. 2 How they knew it so precisely is a mystery. West of the Iron Curtain, the subject rarely is·broached officially. But no Western officialdom lacks open-minded and outspoken members. Close questioning on specific topics brings to light revealing answers. The same official who is indignant about general charges may readily admit dubious· practices in some specific field with which he happens to be familiar.

Practicing doctors should be the natural witnesses. Over whelmingly, their testimony is damaging. But it is being depre cated as biased and partisan. 3 Of course, it is not free of pecuniary considerations. Nor is the judgment of industrialists 92 93 ] THE ETHICS OF COMPULSORY MEDICINE who foot the bill both by their contributions or taxes and by employee absenteeism. However, the evidence of a convicting nature is too abundant to be ignored. Published material that never has been contradicted, officiallyand seems uncontradict able breaks into the open time and again. Evidence of serious shortcomings of the schemes has been produced by their own honest and intelligent supporters who clamor, for a reform of one sort or another. The,shortcomings are further substantiated by the controls instituted to combat them and by the mutual accusations of the' conflicting groups. The clash between·panels (or ministries) on the one side, and doctors on the other is not the only "class·struggle" in com pulsory medicine. The scheme administrations are ,often at odds with their own national ,authorities, pharmacists' organi zations,and hospital managements. The accusations reach at times extraordinary intensity. SOOfieror later, each group turns to publicity for support.

Moreover, administrations, doctors, nurses, pharmacists, almost every 'one connected with the' functioning of the schemes has a great deal to blame on the greediness of the beneficiaries. They in tum blame everyone else. And often even more revealing than the verbal free-for-all are the "be tween the lines" implications of administrative measures. The central caisse of Paris, while denying the system's responsibil ity for absenteeism, placed two "motorized" staff doctors on the job of checking its own employees; the result was an immediate decline of absenteeism from 12 per cent to 5 per cent among its 6,000 women employees. CIRCUMVENTING Compulsory medicine is open to a large THE LAW measure of illegality due not only to the extreme complexity and clumsiness of its mechanism, but also to the very nature of its operations. In Germany, as in France and Belgium" and even in England, rumors persist about people exchanging prescriptions for per fume or toothpaste. Such "minor" infractions of the law-by both the patient and the pharmacist, in ·this example-are relevant merely as indications. Some schemes offer more op portunity for illegal' or extra-legal manipulation than others.

Much depends on the national· "temperament," too. Every where, there is an'appreciable residue of undiluted law-breakCOMPULSORY MEDICAL CARE AND THE WELFARE STATE [94 ing, stemming from the fact that public funds are involved which the individual is inclined to regard as an economic "no-man's land." If it is true that opportunity makes thieves, there must be quite a few around.in compulsory medical systems. Especially so, when those contributing to some extent feel that they do not get equivalent return on their "investment." Take the French technique of sick tickets which the patient has to secure at the panel, to be returned witH the notations and signature of the doctor. What if a beneficiary fills them out himself, falsi fying a physician's signature? One such case was detected in Paris, when a fellow repeatedly.prescribed for himself-at the time of the food shortage-such quantities of cod liver oil that the panel became suspicious. With a little more discretion he might have gotten away with it. What apparatus would be needed to verify the signatures of every one of the some 6,000 practitioners in the Paris area, with tens of thousands of sick tickets coming in every work day?

The new British scheme has found a solution to all such control problems-no checking at all. How much, then, is true of the reports published in the newspapers, by apparently trustworthy people, that eye glasses, wigs, hearing aids, and even dentures are used in the "pubs" as means of payment, new ones to be ordered next morning, is anyone's guess. (An estimated 30 per cent of all eye glasses distributed under the Bevan scheme free of charge are duplicates-not countinp; the renewal orders.) There is nothing to stop a Britisher, as the Select Committee on Estimates of 1949 found out, from hav ing any number of dentures made, if he cares to change dentists.+ Ingenious tricks for contraventing the law, without violat ing it, develop under the Bevan scheme. A couple registers with two doctors; the man's official practitioner is the private doctor of the wife, and vice versa. Each is treated by his or her private doctor whose prescriptions are sent to the official practitioner of the spouse with a stamped returned envelope.

The prescription returns on the official form and the medicine is collected "on Bevan," thus evading the law that prevents the doctor from treating privately his officially registered patient. Such examples of semi-illegal, not punishable evasions could fill a volume. And numerous cases of actual fraud are 95] TH~ ETHICS OF· COMPUl"SORY MEDICINE known to have occurred in the compulsory industrial accident insurance plans as well as in the sickness schemes.5 THE . Crude extra-IegaIity~n~ open illegality are a SUBJECTIVE minor though· disquieting· angle of a funda RISK mental issue. The real problem is one of basic ethics as well as of public finance and of indi vidual health care. It should not be surprising to find that these are three aspects of one and the same· problem: ... of human nature pressed into an institutional set-up that ignores, or pre tends to reform, elementary tenets of human psychology.

The dir~ fact is, to put it bluntly, that governmentalized medieine tends to .bring about a conflict between the natural, perhaps even subconscious interests or instincts of the persons directly affected and the schemes themselves. These conflicts undermine the functioning and negate the objectives of com pulsorymedicine. The crux is what the insurance experts call the subjective risk. Sickness depends on objective causes beyond the control of the affiicted person. But it .also depends on little known processes of a mental and emotional nature. To be sick is,.to an undefinable but very substantial extent, a matter of '.'psy chology." To become a "patient"-admitting or claiming helplessness-·is another process regulated by. purely mental as much as by "factual" happenings. The adage "people who get everything for next to nothing think next to nothing of everything they. get" epitomizes a human reaction so automatic that it is scarcely even con scious. Given the meagerness of our pocketbooks, we cannot help but be rational to the extent of economizing with things which are expensive. But that which is cheap is "cheap as dirt" and need not be treated with care or consideration.

The new apostleof Social.Security,Sir William Beveridge himself, has warned that "the danger of providing benefits, which are b,oth adequate and indefinite in duration is that men, as creatutes that adapt themselves ·tocircumstances, may settle down to them." They settle down, indeed, and "smarten up" to them. They do so.the. more, the longer the scheme is in.operation. What is done at ·first surreptitiously by uninhibited persons only,.tends to become common practice.

COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 96 The real problem is rooted in the semi-conscious twilight in which the behavior of the individual is determined by the interplay of conventional ethics and traditional habits, of rational will-power, economic interests, emotional strains, objective and subjective symptoms of illness, and manifold circumstances. If the factory workers of the Rhone Valley year after year are "sick" for a week or two just at the time the peach crops of their little gardens ripen, is it or is it not to draw the sick benefits (half pay) and to reap other advan tages as well? Or did they merely postpone for a convenient occasion a treatment they needed sooner or later? Similar questions could be raised with respect to the "seasonal" ail ments notoriously displayed by seasonal workers, to the cha grin of all sickness schemes. Their query is how to stop what they regard as unfair exploitation of their resources without hurting the justified claims of the bona...:fide patients.

The notorious coincidence of women's laundry days arid house-cleaning seasons with their sick leaves constitutes an other headache of. the same type to the panels whose budgets have to absorb the bills. Characteristically, the number of sickness cases reaches record figures not only in depressions, among the unemployed (where there is no unemployment in surance), but also in inflations of the type in which black -markets flourish. It then pays to get half-pay from the scheme and to go "blackmarketing." Another widely favored sport is to round out one's one or two weeks' paid vacation by one or two weeks' (half paid) sick-leave. THE ETHICS These are comparatively simple situations, OF SICKNESS although loaded wit!}. consequences. But where is the border between legitimate and illegitimate claims in the instance of hypochondriacs-experi enced panel practitioners estimate them at 10 per cent to 15 per cent of all patients-to whom being ill is a quaint form of recreation? They monopolize the doctors and even the hospitals to the detriment of the seriously ill. What of the army of psychosomatic sufferers, and all the borderline troubles and irregular symptoms? The margin between right or wrong is very thin when the individual lacks standards by which to distinguish, and the community cannot provide effective sa~c tions of enforcement. All that may happen to him who claims 97 ] THE ETHICS OF COMPULSORY· MEDICINE too much is that he may not get it. In any case, he pays no extra price and has no punishment to fear. If he refrains from using the facilities offered (at little or no cost to him), he still has to pay his contribution and some one·else may draw the benefits. And no oneconcemedneed be bothered by his conscience-no rules of conventional morality may have been offended. Moliere's immortal maladeimaginaire could afford the role only by virtue of his money. The modem hypochon driac is not inhibited by such details if he is "insured" in a scheme.

Indeed, what is unethical in violating a police rule-a favor ite pastime of Frenchmen-if it is to one's advantage and ap parently no one else is hurt? Since the idea of the institution is to serve my health and since health is a wholly subjective concept, why should I not make the most of the institution? To assume or stipulate that people should subordinate their oWn concrete interests, as they understand them, to the abstract ideal of a common welfare, which is a vague term to most of them, is as futile as it is typical of Utopian thinking. It presupposes that the common man is something of a hero or saint in his everyday life. And it ignores the role of th'e emo tional dynamics eyen in organic ailments. THE PROBLEM OF The question of consumer-ethics is rele LITTLE MALADIES vant to what is called minor maladies (bagatelle cases). Well-meaning advocates of obligatory medicine like to believe, and to make others believe, that all that is needed is to control the would-be patient who is pestering the doctor with a head cold-or with "cold feet," for that matter-·· and 'similar troubles!and draws sicknessbenefits for periods up to 14 or 21 days. "Minor mal adies ar~ those diseases which the patient thinks it not worth while to take to the doctor" (G. S. Williamson). When the doctor ·is freely accessible, like water or air, anything might be taken to him. The adverse effect on people's morale as well as on their productivity should be.obvious. The problem is particularly serious in the case of irregular workers-. and of offic~ employees, who, in most of Europe, are' entitled to a month sick leave (at the boss's expense).

Officially,the short maladies are defined as those lasting two weeks,in one country, ten days or three weeks,in another. The COMPULSORY MEDICAL CARE AND THE WELFARE STATE [98 time limit is purely arbitrary, introducing an additional ele ment of social injustice and bureaucratic red-tape. In any case, the short maladies are the hypochondriac's paradise and the large family's playground. But "all of them have the mak ings of major maladies," the compulsion advocates retort. Any how, the elimination of the "little risk" in the compulsory system is a political impossibility. Nothing advertises a health scheme more effectively than the fact that a doctor is at every one's elbow literally "at a sneeze." The claim of the French panels that the cost of short mala .. dies amounts altogether to less than 15 per cent of all costs is slightly incorrect. The expense for doctors and pharmacies incurred by patients who do not stop working seemingly is not included in that figure. But inhibited as the French patient is by the extra-fee of the doctor, as pointed out before (Chapter X), abuses creep in. One indirect proof by official statistics of such abuses in the petites maladies is the fact that the moth ers' demand for minor medical care moves in exact proportion to that of their children. Why should French mothers have just as.many stomach aches and similar short ailments as the children? The parallel run of the two figures in practically every single one of the 100-odd panels could scarcely be accidental.

Outside France, the minor maladies seem to absorb as much as 20 per cent and 30 per cent of the scheme expenditures. But chances of over-medication are omnipresent in "long" sicknesses as well. They, too, raise virtually unsurmountable problems-and costs-of control. They are most burden some on the doctor's visiting time, on the specialists, phar macies and, last but not least, on the hospitals. But the real crux is the inevitable effect of the compulsory system on that patient doctor relationship. THE LOGIC What the scheme administrations are most OF ABUSES anxious to prohibit and what they are faced with constantly is the doctor's alleged or real collusion with the patients in providing sick pay for those among the latter who supposedly are able to work. Boswell credits Dr. Samuel Johnson with having said: "No man would be a sailor who has contrivance enough to .get himself into jail." It might be said in earnest that no sensible 99] THE ETHICS OF COMPULSORY MEDICIN~ man· is going to work at ,full pay all the time if· he can have in-between a vacation at half-pay, or a hospital rest at no cost.

W~o has no minor physical or nervous trouble of some sort at some time? As a French doctor asked me rhetorically: "Don't we all need eight ,days' vacation?" Of course we do, but the question is: who will foot the bill, and what will happento the national output if, on top of shorter weeks, shorter hours and legal, paid vacations, we all take out time and ~ga.in an ~ddi tional eight days? These questions are of particular urgency for Europeans whose per man-hour productivity has declined, and whose economic deficit is being paid by the United States. That half-pay with no work has a temporary preference, in the individual's schedule of desirable things, over uninterrupted work at full pay is not only an a priori certainty to anyone who has an inkling of human attitudes toward factory' and office work. It can be demonstrated statistically as well. In every scheme, the number of sick days per insured, tends to rise. France, e.g., is the country where one would least expect it to happen, due to the impediments-such as partly self-paid doctor's fees, and other controls-that the French system puts in the way of the would-be "cheater." But the French figures indicate a' different story. By 1948,per capita sickness days had doubled those in 1938, as pointed out in Chapter VI.

The average beneficiary is "ill" either twice as often or twice as long as before the last war, this at a time when food short ages and black markets have virtually vanished. While the black markets flourished, sick-days ,(at half-pay) stymied French industry. For the third quarter of 1947, as an example, 245 textile plants of the Lille-Roubaix-Tourcoing ,region re ported that of those absent from work, 58 per cent stayed away' less than 8 days, and 19.5 per cent, 8 to 15 days. The overwhelming role of the short malady was evident in that case. The damage 'it causes to industrial productivity may be far more serious .than its coststo the sickness scheme itself. DOCTORS,The mo~e facilities the compulsory s~hemes offer ETHICSj) to the SIck., the more people are ,. SIck, say the · French doctors. JSwiss panels tell the same story' from their own angle. A new specialist establishing himself, they say, builds up his clientele within a year or two without taking away any from the old ones. And it does not take special COMPULSORY MEDICAL CARE AND THE WELFARE STATE [100 advertisement. Hanging out his shingle, with a little announce ment in the paper mentioning his specialty and background, does the trick. All that matters is that he has something new to offer. The demand for medical and pharmaceutical services is virtually infinite. It stems from the desire for lengthening life, multiplying its pleasures, reducing its pains, and generally strengthening body and soul. The panels make a great deal of this point, the implication being that it is the widening of the medical field and the doctor's shrewd propensity to "sell" ever new services to the public that is responsible for the vertical expansion of the schemes and the mounting costs. There is, of course, more than a kernel of truth in these charges. But what the· panels prefer to ignore is the fact that the services are offered·to the public at little or no cost.

Instead, they emphasize that it takes a doctor's signature to be sick and to get "free" services. In compulsory systems, in deed, the signature is almost invariably available for the asking -if not from the first or second physician, then from the third or fourth. There always is a fifth or tenth present who might be willing, unconsciouslyor otherwise, to walk on ethical tight ropes. It is a tight-rope from the point of view of the scheme managers, who in turn have to do something about it-to stop the medical tail from wagging the administrative dog.