.comment-link {margin-left:.6em;}

Mutualist Blog: Free Market Anti-Capitalism

To dissolve, submerge, and cause to disappear the political or governmental system in the economic system by reducing, simplifying, decentralizing and suppressing, one after another, all the wheels of this great machine, which is called the Government or the State. --Proudhon, General Idea of the Revolution

My Photo
Name:
Location: Northwest Arkansas, United States

Wednesday, May 11, 2005

The Right to Self-Treatment

Great post on medical self-treatment at How to Save the World:

In fact, in the US the right to self-treatment was removed in 1914. This adds to the bottlenecks in our health care system, encourages patients to abrogate their responsibility for self-management of their health, and forces medical professionals to do an enormous amount of work that could easily be done by others (including the patient himself), resulting in unnecessary cost to the health care system....

For his assertion regarding the illegalization of self-treatment, Pollard cites Sheldon Richman:

Another way that the government interferes with the authentic right to health care is through the system of prescription medicines. Citizens of this theoretically free country may not use certain medicines without the written permission of an officer of the state. Yes, doctors are officers of the state by virtue of their having been deputized by the state to grant, or withhold, such permission. That was not true before 1914. Until then, adult citizens could enter a pharmacy and buy any drug they wished, from headache powders to opium. They needed no one's permission. They were, in a phrase, pharmacologically free.

That freedom was abolished as the paternalist ethic gained currency. People had to be protected from their own unwise choices. For their own good, they could not be allowed to prescribe medicines for themselves. At least, that is what they were told. In fact, we know otherwise. When Americans were pharmacologically free, they managed not to kill themselves with overdoses or inappropriate medicines. When they felt it necessary, they sought advice from physicians or others who had greater experience than themselves. Americans somehow knew not to swallow purported medicines without wondering about the consequences. (We know this because population and life expectancy grew all during the period.)

Then they lost this right. They were told they were no longer able to make those kinds of decisions. For some unfathomable reason, they surrendered their authentic right to health care without a bloody struggle.

They were lied to, of course. The doctors and the politicians did not really believe that Americans had suddenly become too benighted to medicate themselves. No, the doctors and politicians wanted power. The prescription law was just one piece of a larger conspiracy against the public. At about this time, the United States got its first laws to license doctors and accredit medical schools. The same paternalistic rationalizations were fed to the public. But the minutes of the medical societies' meetings tell another story. Historian Ronald Hamowy has documented what was really on the minds of the doctors: income. They were concerned that free entry, and hence unrestricted competition, into the medical profession was driving down fees. Only government regulation could keep the doctors living in the manner to which they had become accustomed.

That regulation took several forms. Accreditation of medical schools regulated how many doctors would graduate each year. Licensing similarly metered the number of practitioners and prohibited competitors, such as nurses and paramedics, from performing services they were perfectly capable of performing. Finally, prescription laws guaranteed that people would have to see a doctor to obtain medicines they had previously been able to get on their own. The doctors and politicians succeeded in supporting the medical profession's income; they also contributed to the infantilization of the American people. We have never recovered.

The health-care industry is a textbook example of what Ivan Illich called a "radical monopoly." As I wrote in an earlier post, state intervention artificially skews the model of service toward the most expensive kind of stuff. For example, the patent system encourages an R&D effort focused mainly on tweaking existing drugs just enough to claim that they're "new," and justify getting a new patent on them (the so-called "me too" drugs). Most medical research is carried out in prestigious med schools, clinics and research hospitals whose boards of directors are also senior managers or directors of drug companies. And the average GP's knowledge of new drugs comes from the Pfizer or Merck rep who drops by now and then.

The government having made some aspects of treatment artificially lucrative with its patent system and licensing cartel, the standards of practice naturally gravitate toward where the money is. The newly patented "me too" drugs crowd out drugs that are almost (if not entirely) as good, so that the cost of medicine is many times higher than necessary. The licensing cartel requires diagnosis and treatment by someone with an MD's level of training, when something much less might be all that's needed.

Result: Illich's radical monopoly. The state-sponsored crowding-out makes other, cheaper (and often more appropriate) forms of treatment less usable, and renders cheaper (but adequate) treatments artificially scarce. Centralized, high-tech, and skill-intensive ways of doing things make it harder for ordinary people to translate their own skills and knowledge into use-value. Schooling is something you can only get from somebody with a degree from a teacher's college, according to a state-prescribed curriculum. In the field of housing, around a third of which was still self-built in the U.S. as late as the 1940s, self-building is virtually illegal thanks to local housing codes set by licensed contractors and their lobbyists. This despite the fact that the available technology for self-building (modular houses, "cob" building, etc.) is far more user-friendly than it was sixty years ago. And healthcare, finally, is something you can only get from somebody who's spent eight years in school, jumped through the hoop of his local licensing cartel, and done a residency.

The medical licensing cartel outlaws one of the most potent weapons against monopoly: product substitution. As the Chinese barefoot doctor system demonstrated, much of what an MD does doesn't actually require an MD's level of training. Imagine a private system of accreditation with multiple tiers of training.... The "barefoot doctor" at the neighborhood cooperative clinic might, for example, be trained to set most fractures and deal with other common traumas, perform an array of basic tests, and treat most ordinary infectious diseases. He might be able listen to your symptoms and listen to your lungs, do a sputum culture, and give you a run of Zithro for your pneumonia, without having to refer you any further. And his training would also include identifying situations clearly beyond his competence that required an MD's expertise.

I'm very big on the idea of reviving the mutuals or sick-benefit societies that working people organized for themselves, back in the days before the state and the capitalist insurance companies conspired to destroy them. One small-scale attempt at doing this sort of thing is the Ithaca Health Fund, created by the same people involved in Ithaca Hours.

But this alone is not enough. The problem with such systems is they handle only the financing end of things, while delivery of service is still under the control of the same old institutional culture. Any real solution will have to involve cooperative control over the provision of healthcare itself, as well.

Imagine, for example, a cooperative clinic at the neighborhood level. It might be staffed mainly with nurse-practitioners or the sort of "barefoot doctors" mentioned above. They could treat most traumas and ordinary infectious diseases themselves, with several neighborhood clinics together having an MD on retainer for more serious referrals. They could rely entirely on generic drugs, at least when they were virtually as good as the patented "me too" stuff; possibly with the option to buy more expensive, non-covered stuff with your own money. Their standard of practice would focus much more heavily on preventive medicine, nutrition, etc., which would be cheap for members of the cooperative who didn't have to pay the cost of an expensive office visit to an MD for such service. Their service model might look much more like something designed by, say, Dr. Andrew Weil. One of the terms of membership at standard rates might be signing a waiver of most expensive, legally-driven CYA testing. For members of such a cooperative, the cost of medical treatment in real dollars might be as low as it was several decades ago. No doubt many upper middle class people might prefer a healthcare plan with more frills, catastrophic care, etc. But for the 40 million or so who are presently uninsured, it'd be a pretty damned good deal.

And by the way: I object strenuously to those who see a single-payer system, or a government-controlled delivery system like the UK's National Health, as the solution. I'd like to give those who talk about healthcare being a "right" the benefit of the doubt, and assume they just don't understand the implications of what they're saying. But when you talk about education, healthcare, or anything else being a "right," what that means in practice is that you get it in the (rationed) amount and form the State wants you to have, and buying it in the form you want becomes much more difficult (if not criminalized). It means the providers of the service will be cartelized, and that the provision of the service will be regulated according to their professional culture and institutional mindset.

Making something a "right" that requires labor to produce also carries another implication: slavery. Nobody is born with a "right" to somebody else's labor-product: as Lilburne said, nobody is born with a saddle on his back, and nobody is born booted and spurred to ride him.

12 Comments:

Anonymous Anonymous said...

While I agree in principle with your post, I think some of your facts are not quite straight.

For example, I've successfully self-diagnosed and self-treated chronic conditions (for which there are big pharma "solutions") for years with vitamins and herbal tinctures, and only recently got the blessing of a naturopath (licensed ND) that I was doing the right thing theoretically.

It's a loophole that is always threatened with closure, but herb lore is widely available on the Internet, and many formulas have undergone clinical testing in Europe (Germany in particular encourages the use of herbal formulas). Herbals are not regulated by law, many of them are quite potent and have multiple applications, and they are readily available.

Given the side effects of most pharmaceuticals, I always seek out herbals first if possible, particularly since there has been a sort of "clinical testing" going on for ages by virtue of the fact that people use the stuff and it has survived -- ergo, side effects can't be that bad, in general.

Secondly, I don't know if you've ever had to care for someone with a major medical problem, but it is really paradoxical and sort of frightening what healthcare professionals expect of family caregivers, considering the reputation they attempt to maintain. Oftentimes the patient is discharged not fully recovered with a battery of medications and a set of information sheets and after that patient and caregiver are on their own.

It is particularly striking with veterinarians -- I have inserted IV needles into cats, something a human-healthcare pro can't do without a license.

While this tends to illustrate your point about healthcare as a radical monopoly, to say that people are constrained by law so that they can't self-treat is not accurate.

Anybody who has ever gotten that spare bottle of pills from a relative with the same problem can tell you that.

Last, but not least, the system in the US is "sickness care" -- it has nothing at all to do with maintaining good health (and I don't think you are quite right in the assumption that a system organized around big pharma drugs and Western-style medical interventions is the answer).

The "barefoot doctors" of China were allegedly paid by patients as long as people stayed healthy. When sickness struck, payment stopped until the patient was well again.

That is a "health care" system.

Susan

May 11, 2005 1:35 PM  
Blogger tros said...

While this tends to illustrate your point about healthcare as a radical monopoly, to say that people are constrained by law so that they can't self-treat is not accurate.

Anybody who has ever gotten that spare bottle of pills from a relative with the same problem can tell you that.


I smoke pot almost every day, and I never encounter anyone trying to make me stop. I don't think the author is necessarily making the point that nobody can self treat. Just like I have to skulk around alleyways to smoke in peace, self-treating patients must find someone they know who has leftover medicine. We are both "constrained by law".

May 11, 2005 10:03 PM  
Anonymous Mike Jordan said...

After reading this, I am beginning to realize how important the period from the turn of the 20th century up to the First World War was. We always hear about how the 'Progressive' movement (T. Roosevelt, Wilson) did so much to curb the power of the robber barons and such, but what this era really did was usher in the state as babysitter. Sure, there was some important regulation of big business, but it seems the population as a whole begins to become 'regulated' in a big way as well.

And what you're talking about here in terms of medicine sounds like what John Taylor Gatto talks about in terms of education. I believe most of his research pinpoints this era as well.

May 12, 2005 1:30 AM  
Blogger Deleted said...

Scientific management, eugenics and social darwinism were the popular intellectual trends among the powerful in those days. Just as they are now. A few of the more enlightened realized that constant abuse of people was bad for business.

"Progressive" was a clever bit of PR. There's nothing more conservative than delivering a fistful of solutions to people won't stop killing the proverbial goose, and undermining the threat from populists, anarchists at the same time.

May 12, 2005 3:41 AM  
Blogger Kevin Carson said...

Susan,

Thanks for the comments. I'm puzzled, though, as to how you get the impression I believe "that a system organized around big pharma drugs and Western-style medical interventions is the answer." I thought my point was just the opposite: that such methods, while justified at times, are crowding out alternative remedies that are often more appropriate. As for the issue of legality, tros already made my response for me. Even though herbal treatment may be legal in most cases, the legal system (not to mention the govt-cartelized insurance system) facilitates conventional allopathic medicine in all sorts of way while impeding the delivery of alternative medicine. As just one example: chemotherapy is legally mandated in most (if not all) states for children with cancer, despite its liver- and immune-destroying effects; while any clinical treatment centering on Hoxsey's red clover formula is illegal.

Mike and Harry,

Some good comments on the "Progressive" Era. The common thread tying all these things together, I think, was the rise of the managerial/professional New Class.

There is a lot of neocon criticism of the New Class (e.g. Peggy Noonan, David Brooks), but it focuses almost entirely on the educational and welfare bureaucracies and intellectuals in academia or journalism. They almost completely neglect the New Class in the corporate world, and the associated rise of Taylorism--even though the corporate reorganization of the economy was not only the work of this class, but the main reason for its existence.

Harry's last paragraph reminds me of that parable by Tolstoy, about the farmer who felt sorry for his cows, and did all sorts of things to make their living conditions more humane. But when asked why he didn't just do the simple thing and let them go, he replied, "Then I couldn't milk them." Liberals are like a smart farmer who realizes he can get more work out of his livestock in the long run by taking good care of them.

I have to laugh when I hear a managerialist liberal like Hillary Clinton, a former director of Wal-Mart, described as some kind of raving leftist on talk radio. Those people need to meet some real leftists.

May 12, 2005 10:03 AM  
Blogger Charles Hueter said...

...adult citizens could enter a pharmacy and buy any drug they wished, from headache powders to opium. They needed no one's permission.

I have a female friend who has a varying allergy to spider bites. The last one resulted in a nasty black bruise several inches in diameter. So she is understandably concerned when she notices a bug bite on her leg that matches the initial symptoms of a spider bite.

She doesn't have health insurance because her employer doesn't offer it and she can't afford to pay out of pocket. All she really needs is a few minutes with a knowledgable physician to recommend medicines (whether man-made or not) and she'd go off to get the ones she wants. But for all the reasons already mentioned by Kevin and others, she's prevented from taking the simplest and cheapest route by the tightly woven web of market regulation.

I come close to blowing a gasket when I hear both liberals and conservatives describe the situation in America as a "free market" in health care when this is most certainly not the case.

May 12, 2005 12:32 PM  
Anonymous Sunni Maravillosa said...

Great stuff, Kevin! I don't think I could have said it better myself ... and I've been bitching about our socialized medicine system for years.

May 15, 2005 4:53 AM  
Blogger josh narins said...

This is what I always hear from Libertarian-types.

Yes, you are smart. I seriously doubt you will wrongfully medicate yourself. Nor would I think it likely you'd find a guy in an alley to give you open-heart surgery.

But you aren't everyone.

I don't agree with national health care, either, by the way, at least as far as I've ever heard it described.

Now, as a libertarian, you support the legalization of drugs, so the idea of OTC dilaudin doesn't make you inconsistent, but I have a problem with that. Maybe I just don't know enough heroin users (or any, that I can think of) but I have met a whole bunch of messed up cocaine users.

I'd prefer you'd read The Spirit of Laws, and then ask yourself "What is the interest of a Republic in the health of its citizens."

I have my answer. I'm happy (enough) with it.

May 16, 2005 12:38 PM  
Blogger josh narins said...

I mentioned this topic to a friend, and the reply was that a lot of what one could get from a pharmacy in 1914 was sugar-water.

Opium was banned in 1905.

It's pre-anti-biotics.

May 16, 2005 12:46 PM  
Blogger Adam said...

This is on the same topic as the recent "pharmacists for life" mess. Some pharmacists refuse to fill prescriptions for birth control, and defend this with their "Right to conscious". The Democrats want to force them to dispense birth control. Libertarians ask why they have been given the special privilege to dispense birth control in the first place. Chile doesn't require prescriptions for birth control, and in the US doctors will give prescriptions for emergency contraceptives without even seeing the patient.

I think there's no good reason to restrict access to these drugs.

May 16, 2005 1:39 PM  
Anonymous diva said...

just trying to find a place to share the news:
if you get a (bad) spider bite - apply heat! I noticed vast improvement after going into my hottub (set at 101 degrees F)
This was a bite that had been getting progressively worse.... for several weeks..... until my time in the hot tub (jets off)
Tonight I applied a small towel (damp, heated in the microwave) as it is raining outside (our hot tub is outside)
Anyway: heat seems to destroy the venom left behind.
Try it!
(if you need to)

December 14, 2006 9:37 PM  
Blogger Spillersman said...

I do believe healthcare cooperatives are a really good idea. You mentioned nurse practitioners also providing some medical services now done by doctors, they have that at some pharmacies. (Instacare) I don't support the state giving special privileges to doctors licensed with it. Why can't doctors be privately licensed? Why can't doctors already licensed in other states or nations automatically practice without having to go through licensing again in the new state? Why can't we buy health insurance plans across state lines? Why can't other medical professionals do some of the things doctors now do? Why aren't marijuana and other drugs legalized? Why does the government give tax deduction and other privileges for prescription drugs but not for other health items like healing herbs and vitamins? (I'm really big on alternative medicine)

November 25, 2009 3:30 PM  

Post a Comment

Links to this post:

Create a Link

<< Home