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.