Health Care; C. Carson

Clarence B. Carson HEALTH CARE: Cross Questio Crooked Answ AT the sometimes innocent parties I went to when I was an adolescent we occasionally played a game called uCrossQuestions and Crooked An swers." Boys were lined up on one side and girls on the other. Each boy was handed a slip of paper on which a question was written. Each girl got one with an answer. When they had been written, each question had an appropriate answer to it. But they were passed out randomly so that, hopefully, the questions no longer matched the answers when they were read. If all went well, there would be a series of mala props, inanities, and ribaldries. Dr. Caraon haa written and taught extenalvely, specializing In American Intellectual history. The most recent of tllaMvera' books, World In the Grip 01 an 'dea, Is available at $14.95 from The Founda tion .for Economic Education, Inc., Irvlngton-onHudson, New York 10533.

A variation of Cross Questions and Crooked Answers has now achieved adult status. Political in volvement in medicine has made it commonplace without our being aware of it. Let us take a statement first. It is usually worded something like this: UEvery American should have quality medical care." Now, the question, ((Don't you want the best quality medical care possible?" It is tempting to treat this as a straight question, and to make what appears to be the only reasonable answer. Namely, ((Ofcourse, I want the best quality medical care possi ble." From that point on the discus sion degenerates into a debate as to which is the best possible system for providing quality medical care. It may not be a futile debate, but it is apt to be inconclusive because the 271 272 THE FREEMAN May best points have been conceded by the answer given to the question. This is so because ((Don't you want the best medical care possible?" is a Cross Question. It is a Cross Ques tion which will most likely elicit a Crooked Answer. Indeed, it is what one of my professors in graduate school called a false question. A false question is one which can only be answered by giving an answer that will be in some part wrong, regardless of what angle you take on it.

To illustrate, let me give the oppo site answer to the question, a some what perverse answer, if you like. UNo, I do not want the best possible medical care. In fact, I do not want medical care at all. Medical care is not something one drools over, like a steak, the best cut of which everyone should have. I do not long for the ministrations .of physicians or for the comforts of a hospital bed. In deed, my preferences run in the op posite direction, to have as little truck with any of these as possible." The answer is evasive, of course, but it is evasion with a point. I want the question reworded. The first order of business is not the quality of medical care; medical care is only a means, not an end. The quality of life is my main concern, not the quality of medical care. The ques tion might be rephrased this way: What do you want from life to which medical care (and its quality presum ably) is directly related? Now that is a straight question which can be given a straight answer.

My answer would go something like this. I want the use of my facul ties with as little impairment as possible. I want to see, hear, smell, feel, walk, taste, talk, and use my limbs well so that I can function normally. Why? So that I can look after myself. So that I can manage my own affairs. So that I can be independent in order to fulfill my purpose as a man. In short, my con cern with medical care is as an ad junct to my personal independence. Restore the Patient Contemporary medical practice has this as its primary aim. Its aim is to maintain or restore the inde pendence of the individual, to get him up and walking again, to get him to looking after his bodily needs, to get him to exercising his faculties, and so on. The desired goal is dismissal of the patient and a minimal dependence on drugs. In short, good medical practice re quires that the patient be restored to independent status as quickly as in the judgment of the attending physician he is ready for it.

Medical care cannot correctly be considered in a vacuum. When we do so we can only ask Cross Questions and get Crooked Answers about it. It is part of the larger corpus of life itself, and ordinarily a subordinate 1980 HEALTH CARE: CROSS QUESTIONS AND CROOKED ANSWERS 273 part. In the context of the state ments made above, the aim ofmedi cal care-the maintaining and re storing of personal independence is part of the broader aim of personal independence for individuals. Whatever impairs the independence of the individual will tend to be detrimental to the aims of medicine. Government intervention is on a collision course with the best in con tem porary medical practice. This may be clear to some when the mat ter is considered only from the angle of quality medical care, but it should be apparent to all when it is looked at from the broader angle of the independence of individuals. The purpose of medicine is to foster indi vidual independence; the impact of government intervention is to re duce the independence of the indi vidual and make him dependent on government. It is this case that is conceded or ignored when we focus exclusively on quality of medical care.

Perpetual Dependence Here is a story which illustrates how government intervention tends to thwart the broader purpose of medicine by establishing perpetual dependencies. It is a true story. It is even a kind of horror story when its implications are contemplated. Here it is. Several years ago I was living and working in Pennsylvania. My father lived in Alabama and was, when most of these events transpired, in a small hospital in Georgia. One eve ning, I got a call from my sister who told me that our father was very ill and that the doctor had said the family should be notified. Presum ably, he was dying. It would not have been surprising, for he was 88 years old and had not been in good health for some time. We flew the next day to see him. Two aspects of his condition stood out. One was that he had lost weight-in fact, was not far from being emaciated. The other was that he had been having hallucinations.

He was conscious most of the time, knew everyone, and was lucid enough in conversation. Except, it soon became clear to me that when he was at his best he still believed in the reality of what he had seen when he was hallucinating. I spent the better part of a day at his bedside, and he seemed to want to talk about his hallucinations. (He did not call them that, of course, they were to him unpleasant things he had actu ally experienced.) When I talked to the attending physician-in fact, he was the only doctor associated with the hos pital-he was rather vague. His prognosis was that my father might die at any time, or he might live for a while longer. Beyond that, he only observed that it was good for me to visit with my father. I began to 274 THE FREEMAN May learn some interesting, and disturb ing, things about the hospital, too. It was preternaturally quiet, and they tried to keep it that way. There were few visitors, except those who came to see my father. One did not en counter patients in the hallways, though there were several nurses about. On inquiry, I was told that the patients were all old and bedrid den.

In fact, it was not what I would call a hosptial; it was a nursing home with a physician and nurses in attendance, and hospital rates were being charged. Whether all the pa tients were being given tranquiliz ers, I do not know, but my father was. It was a place where old people on Medicare were brought to die. We moved my father to another hospital as .soon as we could get an ambulance. I later talked with the new physician who had examined him there. He indicated that it was too soon to make a firm prognosis but that the vital signs were all good. My father was in no imminent danger, as far as could be deter mined. I asked if the medication he had been given would be continued. No, the doctor said, for the time, at least, he would be taken off all drugs. What about diet, I asked. My father could eat anything he wanted,he said, and would be en couraged to eat. (He had been on a restricted diet under the other physician. ) The atmosphere in this hospital was quite different from the other one. It was alive. Patients were clearly there only temporarily for healing, hOPefully, and recUPeration.

I was there once when the physician came in to see my father. He talked to him about going home, about his getting up from the bed, and about going hunting, which was one of my father's favorite activities. Subtly, he was getting my father to think of getting well and inviting him back to life. Within a day a considerable change had occurred in my father. He was more cheerful; he had begun to eat, and was beginning to do things for himself. Within a short time, he returned home to take up the normal course of his life. He lived for several years after these events, and most of the time he was up and about. The memory of the hall ucinations only faded slowly, but otherwise he was better than he had been for some time. A Cure that Kills From what illness was my father suffering? It is reasonable to con clude, ex post facto, that he was suffering most directly from mal nutrition and drug-induced halluci nations. Add to that the fear that arises from helplessness when one suspects he is terminally ill and is waited on hand and foot. The mal nutrition was no doubt a conse1980 HEALTH CARE: CROSS QUESTIONS AND CROOKED ANSWERS 275 quence of the restricted diet plus an habitual finickiness about eating.

There may have been somejustifica tion for the restricted diet, for he had arteriosclerosis and complained from time to time of angina attacks, though they were not usually se vere. As for the tranquilizers, I can only speculate as to why they were prescribed. Father was inclined to be a noisy patient, groaning and making some loud sound when a pain struck him. The tranquilizers were supposed to keep him quiet, though they did not succeed in doing so. More broadly, he was a victim of the Dependency Syndrome induced by government involvement in medicine. My father had become de pendent on government to pay for at least a portion of his medical care. The physician had become depen dent upon government for much, or most, of his income. This arrange ment is conducive to the establish ing of a relation of continual dePen dence upon medical care in the pa tient. For quite a while before my father had been confined in that small hospital he had gone regularly to that physician's office for injec tions. There was no prospect that he would get well or be dismissed. After each brief session with the physi cian, he was let go with these words, USee you again in two weeks."

So far as a layman may judge of such matters, that man had earlier been a comPetent physician. He had been a skilled surgeon with a good practice. I knew him some two de cades before the events related above, and at that time he was interested in healing his patients, getting them back on their feet, and dismissing them from his care as soon as the situation warranted it. The eventual indePendence of his patients was his goal. In the interval, he had changed. He was no longer practicing medicine. He was practicing Medi care. He had bought the govern ment's line. Government had pro claimed, by its actions, that medical care was a good for the aged. It was a good of such importance that it should be made readily available at the taxpayer's expense. If medical care is such a good, is it not reason able to conclude that the aged should continually receive it? And there could be no doubt that he was dispensing a considerable amount of medical care, or something that had the look of it.

Too Much Care But medical care is not a good. It is, if I may so phrase it, a ubad." Drugs can have disastrous side ef fects. Diets can starve. Lying in bed, even in a hospital, can have de bilitating effects. Dependency on doctors,nurses, and medicines is unwholesome. True, a skillful physician, with sound and indepen276 THE FREEMAN May dent judgment, attentive to the con dition of his patients, can use medicine, diets, hospitals, and all the other paraphernalia of modern medical practice to good effect. This tells us, too, what is good: it is the skill, the sound judgment, the inde pendence, and the careful attention. That is the good for which we should pay, and, having had to pay, we are reminded that it is scarce and should be used only when there is some need. The quality of medical care is a secondary issue. What is at issue primarily in the thrust of govern ment into medicine is individual in dependence. The great aim of medi cal practice is not to provide medical care; it is to restore patients to whatever status of independence is possible. The best medicine is some times no medicine at all. However, that decision should not be made by dispensers of medical care but by medical doctors of independent judgment. Government intervention reduces the independence of physi cians and of the population gener ally. A physician may still heal a particular disease, but he cannot re store the full independence of a man who has become deeply dependent on government. The doctor in the small hospital was not on a collision course with government; he had ac cepted the dependent status of those whom he treated and was bent on perpetuating it.

It is not my purpose here, how ever, to dismiss the question of qual ity. Once it has been placed in the broader context to which it belongs-the quality of life-it can be properly considered. No doubt, most people would like to have a high quality of treatment when they stand in need of medical attention. Thus, some observations on the im pact of government intervention on the quality of medicine are now in order. Why Intervention Fails The tendency of government in tervention is to increase the quan tity and reduce the quality. It does so for three reasons mainly. First, by removing or reducing the cost factor in medical treatment, it increases the demand for it. Given the same number of medical person nel, the result is longer waits in doctor's offices, less attention per patient in hospitals, and a dilution of the quality of what is received. Second, when government pre scribes standards of treatment they are, and must be, minimum stan dards. To put it another way, what ever standard government pre scribes becomes the minimum stan dard. The way this works was well illustrated in housing. Most houses built over the last thirty or forty years have four inches of insulation above the ceiling. Much of this is blown-in insulation. Why? Because 1980 HEALTH CARE: CROSS QUESTIONS AND CROOKED ANSWERS 277 F.R.A. required four inches of insu lation, and that is what most houses got. It was widely claimed that the F.H.A. requirements became the standard of the industry. They were, of course, minimum (and inadequate) standards, something the rising cost of energy has helped to bring to our attention. (The F.H.A. standard having been discredited did not, of course, lead that organization to re tire from the field. It has simply set higher standards which, in turn, be come the minimum standard.) A similar development is occurring in the generic drug movement. If the F.D.A. and other agencies are suc cessful, minimally effective drugs will become the standard. To the extent that government pays for medical attention, it will be in ac cord with minimal requirements.

Open heart surgery with a triple by-pass, will be open heart surgery with a triple by-pass, and that is what will be paid for. In short, far from providing the highest quality medical care possible, we will tend to get the lowest quality which the law allows. Third, government intervention tends to restrain and inhibit innova tion. No standards can be set for that which does not exist, and no price scales can be devised. Weare experiencing already the slowdown that results from having to gain government approval before new drugs can be put on the market. The test ing requirements are already so pro hibitive that men will tend to turn their energies away from trying to innovate. The same restrictions do not yet apply to procedures, but there is an inhibitive tendency there also. The Quality of Life This brings us back, however, to my original point. The quality of medical treatment cannot be fully considered as separate from the quality of life in general. The inno vations which raise the quality of medicine are themselves a product of the independence and freedom of individuals. Reduction in the inde pendence of individuals by restric tions must inevitably result in lower quality medical treatment than would otherwise have been avail able. But medical treatment itself is but an adjunct to the independence of individuals.

In the final analysis, then, there is one straight question that can be asked which, when it is answered straight, provides the answers to the subordinate questions as well. It is this: Do you want that quality of life which is possible when individuals are independent? If so, you will want as well the availability of the high est quality of medical treatment. @ David P. Hunt Two YEARS AGO much of the United States experienced a natural gas shortage of emergency proportions; today, there is a surplus of natural gas. What happened to turn a short age into a surplus so quickly? What similarities are there between the natural gas shortage and today's gasoline shortages? There has been little change in basic natural resources in the last two years to explain the shift from shortage to surplus. New discoveries of natural gas still fall short of an nual production. The ratio of proven reserves to production is still declinDavid P. Hunt Is vice president of The East Ohio Gas Company, part of The Consolidated Natural Gas System.