Political Medicine; H. Sennholz

disposal, is inhuman and highly dis criminatory. It puts politicians and their appointees in charge of an ex tremely important service. It is wasteful of human labor and economic resources, and above all, it generates bitter political conflict harmful to social peace and coopera tion. Medical services, like other ser vices, are subject to a basic economic principle: the demand for any ~~free" service outruns any possible supply. After all, it is basic to human nature and action that the demand for any economic good or service is unlim ited as long as it is ~~free" and ob tainable merely by asking. When the demand greatly out strips the supply, the political au thorities offering the free services and thereby creating the imbalance 175 176 THE FREEMAN March then face agonizing decisions. They may choose to suppress the unlim ited demand by rationing and r:gu lation, and simultaneously expand the supply through ever larger out lays of public funds. Nevertheless, the imbalance can never be cor rected as long as the services remain free and their potential demand un limited. But it is likely to create serious political conflicts on the measures to be taken.

Limited Funds Government resources are always limited to the income and wealth that can be taken from its people by taxation, borrowing, or inflation. When a national health service is to receive more public funds, they must be taken from the people. The victims resent and oppose the mea sure that reduces their income and wealth and limits their spending discretion. It provokes a serious political conflict between the advo cates of national health service spending and the victims who are supposed to provide the financial means. But, the sharpest conflict is likely to ensue between the various recipi ents of public funds. The growing needs of a national health service are in direct competition with the demands of social security, govern ment spending on education, wel fare, housing, and all the other de mands on the limited resources of government. All will fight over the government dollar, proclaiming emergencies and clamoring for top priorities.

The fight over public funds is a political fight that is decided from year to year on the floor of the U.S. Congress. When the Congress adopts the U.S. budget, it imposes a ceiling on total government medical expenditures. The very existence of a ceiling denies and refutes the lofty pretension that a national health service will provide all the needed medical care. The spending ceiling itself then generates an ugly conflict between the numerous branches of the health service. After all, there are 101 dif ferent aspects to medical care and 1,001 specialities that are deserving of the government dollar. And once again our politicians on the floor of the U.S. Congress, most of whom have no medical knowledge, must vote on priorities from eyeglasses to false teeth. Politicians always follow the line of least resistance. They readily give in to medical demands that yield their results quickly and visibly and make a political splash. Inversely they discount and neglect slowly maturing results that are not quickly noticed and pay no political dividends. The pressures of im mediate demand always conflict with the preparations for the remote future when the present politicians 1978 POLITICAL MEDICINE BREEDS SOCIAL CONFLICT 177 may no longer be in office. There fore, politicians rarely take a longer view, which in medical matters causes them to discount the impor tance of preventive medicine, the construction of new hospitals and medical schools, occupational health services, and medical research. In stead, they tend to opt for a free supply of drugs, of doctors' services, and of hospital care.

Deteriorating Service In a political medical care system, the hospitals tend to deteriorate and the number of hospital beds de clines. The system suffers from the insufficient medical equipment, especially newly invented machines that revolutionize established pro cedures. In short, it suffers from all the rigidities and lethargies that characterize centralized political management. But the worst consequence of such a system is the inevitable shortage of hospital beds, medical equipment, and doctors. This creates long wait ing lists for medical care people want and need. In England the Na tional Health Service has an aver age list of more than half a million people waiting for what NHS calls ((noncritical surgery." Many people have to wait for years, or never receive medical help in time. British medical literature is full of horror stories about the consequences of such delays. The doctors themselves are crushed by a huge burden of work.

They have so many patients de manding free medical attention that there is only time and strength for minimal mechanical practice. Doc tors see one hundred or more pa tients a day for a few minutes each, give cursory examinations, and hast ily prescribe something that they hope will do no harm until the prob lem goes away. The patients com plain about their careless treat ment, and the doctors complain about the patients' attitude. The doctor is e~pected to be available to all, at any time and for any ailment, real or imagined. Morale among physicians in a na tional health system tends to be very low. After all, no matter how they serve and labor, their remu neration is determined by budgetary considerations and political deliber ations of fairness and adequacy. A given allocation of funds for remu neration must then be divided among the various groups of doctors in the national health service, the general practitioners, the spe cialists, the hospital staff from the senior surgeon to his junior as sistants. With limited total funds, the health service administration must make most unpopular deci sions of division between the various groups and its individual members.

Even if the administration does not use its remuneration power to 178 THE FREEMAN divide and conquer, which it may be tempted to do, it cannot avoid creat ing suspicion and discontent. The physicians, on the other hand, with this great economic power of the health service administration over them, have no choice but to organize and resort to collective force. In the end, the problems of medicine be come largely political, the physician a politician who is lobbying for the economic interests of his group. In Government in Medicine Great Britainjunior hospital doctors are frequently picketing their hospi tals when they are not lobbying for political action. A redistributive society that transfers income and wealth by political force is a conflict society. A national health service that allo cates benefits and determines re muneration by political force not only is harmful to national health, but also breeds social conflict. @ IDEAS ON LIBERTY THE ADVOCATES of government in medicine point to our· overcrowded hospitals as though they have in mind a solution for the problem. But the fact is that much overcrowding is traceable to increased voluntary insurance benefits, a situation that would only be aggravated if all beds were ((free." The waiting lists for the hospitals of England and Germany are so long that many patients finally gain admittance only to have forgotten why they applied.

The hue and cry of overcrowded hospitals is a twisted statistic, for the beds are overburdened with people who are not really sick. The third party in the. form of health insurance has entered the picture. But the present sad picture, with only part of our population voluntarily insured, would surely be magnified if health insurance coverage were made universal and compulsory. Experience with socialized medicine shows hospitals so overcrowded that the situation becomes near impossible, doctors so overworked that their patients get less and less real treatment, the cost of drugs reaching astronomical figures, the total cost of the social system soaring, and the government calling for investigations. CHARLES G. JONES, M.D., Free Medicine Can Make You Sick Ralph Bradford MakingSense Out of the OUR house guest was a. handsome bachelor of around forty· 'whom we had not seen since he was a teenage boy_ As a very young man he had left high school and joined the army, where he served out an enlistment of several years. Returned to civil ian life, he finished high school and went through college by means of the G. I. Bill's provisions. Mter that he got a good job with one of the government departments in a west ern state.