In his posthumously published novel “For Us the Living”, Robert Heinlein refers to “the US Medical Academy.” This is where all the doctors are trained in his fictional World of Tomorrow. He’s not specific in how it all works; his point is that things could be different and still work quite well.
We could train bright people to do heart by-pass surgery. No need for years of med school. Just follow the procedure step by step, like it says in the flow-chart; There would need to be recognized levels of skill: apprentice, journeyman, master. Two years of technical training, followed by testing, apprenticeship, and certification; Clearly, a master by-passer would make good money. Possibly as much as a master plumber.
Master bypasser? Okay, we’d also have to develop good terminology, but we’re Americans; we excel at that.
I maintain that the success rate would probably be as good as we have now, and the whole thing would be way cheaper. To the extent that patient outcomes were suboptimal, this would be offset by enhanced access. (See? Think a European could have coined that phrase? And I’m just an amateur. We rule!) But it’s not just about medical efficacy. There’s a whole set of social consequences to consider.
Taking the money out of it would, well, take the money out of it. Prosperous doctors need insurance to protect their assets from their own fallibility and from predation. An insurance company is a big pot of money held in reserve for emergencies. Money attracts lawyers like blood attracts ticks, in an ecological sense. That’s not to say that lawyers are uniquely wicked. In the past, money attracted armed bands of Anglo-Saxon reivers, so there’s progress, of a sort.
My point is that it’s an ecological process. Exterminate the brutes (I’m referring to the ticks, of course) and something else will emerge to take their place, because the blood is a tempting target. Blood necessitates bloodsuckers. Would you rather have tiny blood-sucking hummingbirds?
Of course people would oppose adoption of this new system. They’d cite safety concerns; They’d point out that only a highly trained physician could respond to the unexpected. Ignoring questions of cost and availability, they’d launch ad campaigns featuring the grieving and the grateful. Every identifiable group that’s part of the existing system, except the anesthetists, would line up to fight the changes. Even if it were finally adopted, my ingenious new system would evolve as part of an ecology as well.
Suppose we had a large union of smart, well-paid technicians whose livelihood depended on doing bypasses. What might the consequences be? Think that’d have any effect on surgical innovation? Would the union lobby urge caution in the approval of new drugs? How hard would it be to get into the union? Would the union have any political clout?
But this isn’t really about unions, or even the medical system. It’s about the limits of directed action; Our inability to do just one thing. Our whole system is so tightly optimized and interconnected that any change comes out somewhere else almost immediately. It’s the law of unintended consequences, on steroids. Faced with such a system, how might we move forward?
- We don’t; we just muddle along while avoiding complete collapse;
- Pursue a course of incremental, opportunistic change and hope it leads to a better arrangement tomorrow;
- Scrap the existing system, more or less violently, and replace it with a better system.
The third option is the most risky, but has the biggest potential payoff. If applied to the whole society, it could lead us to a workers’ paradise. A society of peace, justice, and universal prosperity that would endure until…
Right; until protestors tore down the wall and burned the headquarters of the secret police. So that one’s out.
I guess we have to choose between one and two.