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Conspiracies against the laity part 3298: the medical profession.

Well wouldn’t you know it. A surgeon who transmitted antibiotic resistant superbug during operations on people’s hearts doesn’t want you to know he did.

Apparently John Chen Lu ‘a heart surgeon who infected 11 of his patients with a lethal bug, five of whom died, has taken his fight to keep his past secret to the High Court as he claims revealing the full history is “irrational” and will end his career.’ (By the way, one of the joys of this article is to see the journalist mis-spell ‘principle’  over and over again.) Now I’m not very interested in the facts of this case. Mr Lu claims he is no greater risk to patients than any other heart surgeon now he has been cleared of antibiotic resistant strain of staphylococcus epidermidis . Some senior colleagues apparently do not agree and the relevant Hospitals trust has placed relatively onerous conditions on him returning to surgery.  I’ve no idea, but none of this really matters. What really matters is the general secrecy of the medical profession about the quality and performance of doctors.

I commented some time ago on the immorality of the profession for failing to speak out about known dangerous colleagues. In this particular case there is an element of unfairness in picking on Mr Lu. I’m quite sure many things we’d like to know about heart surgeons are being kept secret from us because we (in their opinion) are irrational and cannot be trusted with the truth. And, indeed, it is hardly surprising they have this opinion, because the welfarist ideologues responsible for the welfarist ideology that underpins the health service in which they work generally regards the public as irrational and ignorant of their own best interest. They are confident that it is a far far better thing they do in running our lives than it would be if they minded their own business and  let us run our them. So why should we be told about the surgeon in whose hands our life is placed?

I’m not sure what there is to do about this. The health services are so corrupted by treating them as different from normal goods that it is not surprising when all sorts of weird norms and practices result. Any supply of anything that is unconstrained by vigourous competition and undisciplined by the need to respond to what the paying customer wants is liable to end up like this— a very very old point by now: Adam Smith pointed it out some time ago.

Nevertheless, the openish secret (secret because deliberately and legally suppressed, openish because obvious to anyone who has had the misfortune to get caught up in them) of the corruption of the family courts by their systematic secrecy has now become less a secret and more open, due largely to the rejection of secrecy by the new head of that court (shame on the previous heads). So I suppose there is some dim hope that the health service gods might be shamed into telling us supplicants of the health service a bit more about who is treating us. But I’m not holding my breath. The incentives are all skewed and we only hear when, as it rather looks in this case, the health service gods wish merely to disencumber themselves of an embarrassment.


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9 Comment on this post

  1. Dr Shackel,
    I agree with the thrust of your post on challenging the secrecy of professionals, but fail to follow you when you blame “welfarist ideologues”. What makes you think that a free market would be better ?
    Your previous post cites the work by Makary on medical silence concerning incompetency : unfortunately for your case, it was done in pre-Obama reforms in that haven of free-market medicine, the USA….
    You cite the welcome changes on secrecy of family courts in the UK : has this change come about through privatising the UK justice system?
    We won’t stop bad practice by wrongly identifying the causes.

    1. What makes me think a free market would be better is all the economists’ arguments for why free markets are better, including those specifically directed at health services. The US has not been a haven of free market health care for a very long time. The government interfered in numerous ways, including forbidding the practice of medicine without a government licence, mandating the content of health insurance and preventing the free entry of competition in health services. On identifying the causes of secrecy, I refer you again to the economists’ arguments on the systematic distortions that un-free markets produce. The point of mentioning the secrecy in the family court was nothing to do with causes and only to give an example in which, finally, the appalling consequences of making secret what should not be were being recognized.

      1. >What makes me think a free market would be better is all the economists’ arguments for why free markets are better, including those specifically directed at health services.

        Since there are economic counter arguments (mainly to do with moral hazards, partial information, and the principal agent problem), theory isn’t enough to decide anything on this field, we need empirical evidence. And the empirical evidence from cross country comparisons seems to be that the best healthcare systems in existence are mixed state/private (France, Germany), and the most efficient in terms of value for money are fully state owned (Canada, GB). There’s also the interesting example of Singapore. If you’re claiming free market superiority in healthcare, I’d want to see statistics, not arguments.

        1. Neither the arguments nor the theory are a priori and they do indeed decide this. The items you mention are not sound counter arguments and to mention them as you did perhaps means you are unfamiliar with the demonstrations by economists of how markets deal with them. I’m not sure what empirical evidence you are speaking of but there is available plenty of empirical evidence for the superiority of market provision– if you want to find it, of course. Singapore is one of the more market based systems. See McArdle on it:

          “Why does this system work so well? Because it incorporates the central idea behind free-market health care: that health-care spending is most efficient when that spending is executed by individual patients, rather than third parties. It’s easy to waste other people’s money. But if that money is your own, you are going to try your best to spend it wisely.

          “Singapore installed this system relatively recently. Prior to 1984, the former British colony had a system quite similar to that of Britain’s National Health Service. In that year, the government reversed course, with impressive results. ”

  2. I also find the link between the secrecy of professional and “welfarist ideologues” somewhat strange. As usual this type of link is accompanied by a misunderstanding of Adam Smith. He did not believe that the supply of all goods and services should be subject to the disciplines of the market. The post office he cites as having been successfully managed by every sort of government and should remain in state control. (Strange how the Adam Smith Institute and others that use his name said nothing about this when it was privatised last year.) Smith would have observed the NHS to see how it functioned and in this case would have blamed the bad practices of the medical profession. The NHS should drive out these practices, but he would be quick to realise that the situation is no better, if not worse, in private medical systems (he had much to say about that in his own time). Of course he would be highly critical of the NHS, but there is nothing in his writings to suggest, given the advancement of science, that he would unquestioningly see our corrupt market disciplines as being the only solution to its problems.

    I am sure that Smith would agree, ’We won’t stop bad practice by wrongly identifying the causes.’

    1. In mentioning Adam Smith I was not making an appeal to authority but merely noting how long we had known the point. You, however, are.

      If Smith had blamed the bad practices of the medical profession he might then have raised the question of the cause of those bad practices and come to the same conclusion as mine based on the same truth about markets. But whether he did or not is irrelevant. What is relevant is simply the truth of that general point. Free markets are nothing in themselves but merely what emerges when free people trade freely. They are better than other options because such trades always make both participants better off. Market discipline is what emerges in such circumstances. Market discipline is being constrained by vigourous competition and by the need to respond to what the paying customer wants. If you don’t make others better off they won’t make you better off. As such market discipline is not corrupt. Suppliers compete on many margins and one of those margins is honesty and the long term satisfaction of customers. Free entry for such suppliers, only possible when others are not protected by governmental restrictions on entry, drives out dishonest suppliers.

      I’m sure Smith would agree that we won’t stop bad practice by wrongly identifying the causes and that is why I am fingering the major cause. Of course, if we continue to refuse to fix that cause then we’ll do other things instead, things that are more expensive and less effective. We will continue with people spending 4, 5 6, 7 8, 9, 10 hours in emergency waiting rooms, people being left on trolleys in wards to pretend that government targets are being met, ignoring immobile or incontinent elderly patients to soil themselves in their beds, retaining known incompetent and dangerous medics in post, killing lots of people and covering it up, etc etc.

      1. The point I was trying to make is that Smith did not think that the supply of all goods and services should be in the private sector, and, given the progress in medical science and care, it might now be one of the services he would keep out of the private sector.

        Smith discusses the medical profession within the context of the existing 18th century “science” of physic, which he regarded as being expensive ’quachish arts’. Of course he believed that most of the bad practices of the medical profession would be corrected if it was subject to market disciplines because it would expose the quackery and more people would use the free service provided by ‘old women in the country [who] practice physic‘ (Letter to Dr Cullen, 20/9/1774). We cannot assume he would think that today’s medical science and care would be better if it were in the private sector because inter alia we are still nowhere near the free market system he envisaged. There is no evidence that the distorted market system we have now, as in his day, is able to deliver a proper and affordable medical service that covers all conditions for every citizen. Even if we assume that the market could be reformed (again there is no evidence that this is happening), we should still consider whether a modern medical service operating within our science would be better off in the market (progess in science could be a game changer). Smith believed that the effects of the engine of the economy – the division of labour – would eventual enfeeble the intellect and morals of society (later developed by Marx), and that it was the responsibility of government to ameliorate the conditions of its citizens by providing education, entertainment and cultural actives. A modern state run health service could now be seen as another intervention into the corrosive effects of the division of labour.

        These issues are far more complex than ‘merely noting how long we had known the point’ about free markets. If you cite Smith as the champion of the free market, you must recognise that although he believed even a distorted and corrupted free market was on balance better than other economic systems, he was highly critical of the system he observed and would no doubt be even more critical of our system. Even if we could obtain “ideal market system” you outline, we cannot automatically assume, as I have said, that a modern health service would perform all the functions we need if it were in the private sector.

  3. I think that the problem of corruption comes from two sources. First, is our society’s reliance on “experts.” Many of us actually believe that a degree or a symbol of “education” like letters after someone’s name actually means something – namely that the person is moral, intelligent, and well educated. Obviously, education is a good thing – but it rarely guarentees morality, sanity, or intelligent actions for the common good!

    The second problem is the greed and selfishness of most of us and a lack of oversight in many professions. If doctors can get away with hiding their disease or incompetence, some portion of them will!

    So, in certain professions – we need better oversight. In the meantime, we need to educate people that they need to protect themselves by not assuming “experts” are necessarily capable of protecting us. It means asking lots of questions, judging the character of our doctors ourselves, looking up information about the medicines they give us, etc. Many errors occur simply because we have granted this profession way too much credit.

  4. >generally regards the public as irrational and ignorant of their own best interest.

    You’ve demonstrated that experts will sometimes/often behave in self-interested ways. But do you have evidence that it would indeed improve things to bring the public on board? I’m talking efficiency, not morality here: if you take people as a whole and dump masses of information on them about medical issues that they lack the training to interpret, do you have evidence that this would improve outcomes?

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