THE LIBERTARIAN ENTERPRISE
Number 165, March 18, 2002
Ides of March
Medical Care for Free Individuals
by William Stone, III
Exclusive to TLE
Much to my surprise, I recently discovered that America actually has a health care problem.
I've known for years that health care was much too expensive, for reasons that are obvious to any non-statist. What really surprised me is exactly how bad the health care problem is.
Its solution, of course, has nothing to do what the statists in Washington and their sycophants the "free" press would have you believe.
As a teenager, I noticed that the left side of my nose stuck out a little farther than my right. I bemoaned this fact in terms of it being a deficit to attracting girls, but gave it no more thought.
Over the years, I've experienced persistent sinus problems. In 1997, I spent eight months with sinus infections. Last year, it was close to six months.
However, last year - by virtue of living in a small town in South Dakota as opposed to Chicago - I saw the same general practitioner at each doctor's visit. In short order, she discovered that her usual course of treatment wasn't working and sent me to the hospital for a CT scan. At this point the details of my unusual sinus physiology - and their impact on my healthy - became obvious, and corrective surgery was scheduled.
I'd never had surgery previously. With the exception of my daughters' births, I've never been in a hospital except as a visitor. The experience was such that I'm inclined to take really good care of myself so that I need never see the inside of a hospital again. The experience was appalling, from beginning to end.
First came the predictable delays. My surgery was scheduled for 9:15am, and I was asked to arrive at 7:45am. I wasn't called to have my intravenous drip inserted until 9:00am - meaning there was no chance of making the 9:15 surgery.
Those in the medical profession don't really seem to understand the effect that delays have on a patient. Let me put this as succinctly and clearly as possible:
Surgery scares us. Even relatively simply outpatient sinusoidal surgery is frightening. If you're a normal human being, the notion of being unconscious while doctors stick a tube down your throat so you can breathe, break your nose, and thread mechanical devices into your head should scare you.
Sitting in a waiting room watching weekday morning TV while wondering what's taking so long does not make you feel better. All it does is give your imagination time to run wild.
When I was taken to have my IV drip inserted, I was led to what amounts to a large room with beds, separated by thin curtains. I was then invited to strip off my clothes and put on the dreaded "hospital gown."
I'll grant the medical profession this: since my last daughter's birth, patient care has advanced to the point where if you know how to tie the gown correctly, it will cover your behind.
I don't know who thinks that these conditions represent anything like privacy. Certainly no one outside the medical profession.
At this point, I experienced another delay of approximately an hour and a half. This time, my imagination was fueled by an elderly man ten feet away from me who was awaiting a triple bypass operation. I know all the details of his case: he received teary-eyed visits from all his relatives. A couple of cotton curtains do not qualify as soundproofing.
While I was intellectually capable of saying to myself, "Well, at least I'm not having heart surgery," listening to the personal lives of an old man and his grandchildren does not have a positive impact on your mood.
By the time I was finally transferred to a wheelchair and taken to pre-op, I had experienced not only the old man and his family, but the victims of an automobile accident who were wheeled past. Again, this is not conducive to a positive mental attitude.
Then things really got awful. I suffered yet another two-hour delay, during which time I was treated to the most appalling examples of bedside manner that it's ever been my misfortune to witness. Indeed, it reminded me of a triage scene from M*A*S*H.
At one point, an elderly lady was brought in complaining of chest pains and difficulty breathing. When the surgeon on duty examined her, there was a pause and then he asked if she'd ever been told she had heart problems. She replied that in 1991, she'd been told about a heart murmur. In a tone of voice more appropriate to discussing the autopsy of the one of the accident victims I'd seen previously, he said:
"Well, ma'am, from listening to your heart, it sounds like one of your ventricles isn't functioning at all. You've got a very serious problem. We'll give it a shot, but it's really bad."
I couldn't believe my ears. The doctor was essentially telling the woman her days were numbered, but his choice of words and tone of voice were likely to frighten his patient into shock.
I wish I could say that was the worst of what I witnessed. Appallingly, it was not.
Shortly afterward, a nurse brought in a 35-year-old woman who was morbidly obese (she gave her weight as 350 pounds) and suffering from lung and heart problems.
The first thing that happened was that the nurse who delivered the patient was thoroughly chewed-out by the pre-op nurse. It seems that the pre-op nurse didn't feel the job of transferring the patient to a bed should lie with her. Three strapping orderlies were located. In a manner more consistent with moving a piano than a pathetically infirm human being, the orderlies transferred the patient to a bed.
It didn't stop there, either. This poor woman's horror story was only just beginning.
The doctor arrived, examined her, and suggested that they would need to insert something into an artery in her neck. The doctor said to the patient (again, in that callous tone of voice):
"Ma'am, we've got to get this thing inserted, but you're really heavy and have a lot of fat in your neck. I don't know if I'll be able to find an artery. I'll give it a shot, but I can't promise anything."
He then proceeded to spend a lot of time poking, prodding, and pushing. He ultimately had to call an orderly to roll the patient over a couple of times, all the while complaining about the difficulty finding the artery.
When he finally did locate it, he let out a surprised gasp and said, "Dammit - that's a lot of blood - can we get somebody here to clean this mess up?"
Finally, just to add insult to insult (as they had already added insult to injury), as the surgeon put away his instruments, the nurse said to him:
"That took quite some skill, Doctor, to even find the artery."
"Skill? No - that was just dumb luck. I had no idea I was going to find anything. I think I probably went completely through the artery a couple of times and didn't know it because of all the fat."
Keep in mind that while I never saw the patient in question, the only thing separating us was a thin cotton curtain. And in any event, they made these comments in front of the patient.
While this was absolutely the worst example of a doctor's behavior during my surgical experience, there were a number of examples of extraordinarily bad design and planning that resulted in what can only be termed callous treatment - if not outright mistreatment.
For example, as I was trying to recover from the shock of overhearing the trials of the poor woman next to me, I heard the unmistakable sound of a defibrillator charging and then being discharged.
Now, it may be that they were only testing the equipment - or it may be that some poor soul within my hearing experienced a coronary arrest. Perhaps it was the elderly gentleman from the IV insertion area. I don't really know, but by that time, my mind was working overtime imagining the worst possible things that could happen to me.
Then they wheeled in an accident victim with a broken arm. Again, the doctors treated her utterly callously, and again I heard the phrase, "I'll give it a shot."
Let me give the doctors among my readership a tip: "I'll give it a shot," is not something a patient should ever hear out of your mouth. It doesn't matter if you think that what you're doing has no chance of working, you should never say it.
A patient does not want to hear that their condition is permanent - or worse, terminal. They're probably afraid for their lives already. What a patient needs to hear is the gentle, firm conviction that the treatment you're about to give is correct and will at least alleviate - if not eliminate - the problem.
In a classic example of extraordinarily poor architectural design, the surgery pre-op area adjoined the recovery area. It was literally on the other side of a couple of inches of drywall behind me. There were no doors separating the area, just a fifteen foot wall/partition.
Unfortunately, some poor infant was in the recovery area.
I can't speak for other parents, but since the birth of my daughters, I can't stand to listen to a child in any kind of pain. I can't watch movies where awful things happen to children. I can't bear to watch coverage of the Andrea Yates trial - and she's really lucky I wasn't on her jury. Before I had children, I used to like dead baby jokes; now I can't stand them. Anything that involves pain or cruelty to a child simultaneously sickens and enrages me.
The poor infant on the other side of the partition wailing its lungs out very nearly sent me over the edge.
After what seemed like an interminable delay, the anesthesiologist from my surgery stopped by to explain his role. When he was done, he asked, "Do you have any questions?"
While I was by no means eager to get into surgery at this point, I was nevertheless desperate to get out of pre-op. I told the doctor:
"Well, you know, Doctor, sitting here the last hour or so, I've come to the conclusion that I made the right career choice when I went into computers. So can you tell me when they'll be ready to take me into the operating room?"
I got a quizzical look. "I don't understand."
"Well ... I'm saying that sitting here, listening to everything, I've discovered that I just don't have the ... constitution ... to deal with the sorts of things you guys deal with all the time. So I'm kind of interested in getting into the O.R."
He stared at me like I'd suddenly sprouted two heads. "I'm sorry, what ... ?"
I began gesturing at the partitions around me, then pointed to my ear and mouthed the phrase, "I really don't like hearing all this." What was he going to do, make me come right out and say that these pathetic cases were driving me nuts and I'd rather be under the knife than listen to them?
Again, he gave me a deer-in-the-headlights look. I realized that he was so appallingly inured to the callous treatment of patients that he really had no conception of its effect on both the patients and the witnesses to it.
"Forget it, doc - I'm just curious when I'm going in, is all."
So he helpfully went to ask, returned, and told me it would be about half an hour. It was, naturally, double that.
When they finally came for me, I was a nervous wreck, due entirely to the surroundings into which I'd been thrust. In reality, my surgery was fairly minor - noninvasive even, since they do all the work through the nose without incisions. But after a morning spent in the horrors of pre-op one would need a stronger constitution than I to not be scared out of their mind.
From the moment I entered the O.R., I decided that I'd do my level best to not be a part of the problem. They administered my general anesthetic, and as I was starting to get woozy, I could hear the anesthesiologist asking me questions about how I felt. I murmured something non-committal, and then, as loud as I could say through the haze descending on my mind, I called out:
"I see dead people!"
There was general laughter, and I lost consciousness. Always leave 'em laughing!
When I came around in the recovery room, I made a distinct effort to sound upbeat, happy, and positive. I made jokes, repeated the "I see dead people," line when asked by a nurse how I felt, and generally tried to put on a good show for the benefit of anyone listening in pre-op.
I wish that I could say this experience took place in some inner-city hell-hole. I wish I could write it off as an unusual aberration. I wish I could, but I can't. It occurred in a hospital with an excellent reputation in Sioux City, Iowa. If it's that bad in Sioux City, it's probably that bad everywhere. Or worse.
So far, the surgery's been a resounding success, correcting everything it was intended to. During the resultant week off for recovery, I had a lot of time to ponder why the experience - indeed, the system itself - is so horribly flawed.
I couldn't help but contrast current patient care with that common in my grandmother's day. My grandmother - an elderly pioneer of the American West - occasionally tells of her hospital experiences delivering her five children (ell, almost five hospital deliveries - one of them didn't wait until she got to town).
In my grandmother's day, it was commonplace for a mother and newborn to be in the hospital for a month after delivery. Today, unless you have extenuating circumstances such as a Caesarian section, you'll be out in two days. I'm certain that the lack of professional care accounts for many complications in both mother and child. Indeed, my sister and her first son were ejected from the hospital in 24 hours, resulting in my nephew contracting pneumonia a day later.
In my grandmother's day, house calls were commonplace - even though the nearest town to her ranch was more than an hour's drive under the best of circumstances. Today, the house call is considered a quaint hallmark of the past - something to be derided and laughed at when you watch "The Brady Bunch."
However, no one can argue that receiving professional attention for a month after delivery would be beneficial. Nor can one argue that getting out of bed to go sit in a doctor's waiting room is anything other than awful when you're sick.
Leaving aside for a moment the element of care, there is the issue of cost to consider:
Prior to WWII, costs were so low that my grandparents - whose lifetime income is less than many individuals' annual earnings - could easily afford to pay for hospital care for a month.
That's hospital care for a month for five children.
Think of it. In the early part of the 20th century, dirt-poor cattle ranchers in extremely rural South Dakota - an area that's still unbelievably remote, undeveloped, and poverty-stricken by modern standards - could afford to pay for hospital care for a month for five children and their mother. Neither did they have medical insurance to draw from: they paid out of their own pocket.
Today, anyone paying out of their pocket for a month of hospital care is either independently wealthy or about to file for bankruptcy.
What happened to this kind of care and affordability?
The answer is simple: government.
Prior to WWII, there was almost no Federal intervention in the health care industry. As such, health care was subject to the same market forces as any other product, and with the same result: lower costs for higher levels of service.
Then the FedGov got into the picture. It put Unconstitutional price controls on medical care. It invented Unconstitutional programs designed not to help the needy but to create whole classes of people who depended on the FedGov for medical care. Insurance companies took advantage of the business opportunity, inserting themselves as a middle-man between the patient and the doctor. Ultimately, insurance companies bribed FedGov officials - sorry, made "campaign contributions" - and got their position solidified by Unconstitutional law.
It's been downhill ever since.
Partly, too, the problem is due to the doctors' union - sorry, the American Medical Association.
Prior to the 20th century, there were essentially two classes of medical doctor: the physician and the surgeon.
A physician was an individual who made the rounds of his patients every day, treating common illnesses. A surgeon was an individual at the hospital who actually performed operations. The two classes of doctor didn't have the same training, because it's obviously not necessary. A General Practitioner (in today's parlance) rarely performs surgery. A Specialist is a surgeon in a particular field and never performs GP work.
Via Unconstitutional FedGov intervention, the AMA eliminated the physician. Today, all medical doctors are - needlessly - surgeons.
These factors - driven entirely by Unconstitutional FedGov intervention - act to completely divorce health care from market forces. Further, the primary customer of a medical doctor is not an individual patient, but rather that patient's insurance company.
Small wonder that patients are treated so callously.
In a free society in which individuals self-govern guided by the Non- Aggression Principle, things will be radically different.
In the first place, the cost of health care will be radically lower because there will be no AMA-induced physician shortage.
Freed from requiring the intestinal fortitude to perform surgery, the job of physician will attract intelligent individuals who presently go into fields like engineering and computer science.
Indeed, were it not for surgery, I might have been inclined to have become a physician. In my college days, I spoke with a number of engineering students who'd have preferred to be doctors but didn't want to perform surgery.
Contrary to what many of today's surgeons might claim, there's really no need for anyone who treats the flu on a daily basis to be a surgeon. Indeed, eight years experience as a father has taught me that a gallon of Amoxycillin syrup in the house would be enough to keep my kids out of the doctor's office almost entirely.
Imagine it: a free society in which medicine (indeed, all chemicals) are unrestricted consumer goods, the same as TVs, VCRs, and computers.
In a free society, when one of my daughters complains of an earache, I'll exercise some judgment and in all probability make a quick run to the drugstore. I'll plunk down a couple of fractional copper ounces and purchase a bottle of Amoxycillin. There'll be competing brands, as well - the same as there are fifty different kinds of cough syrups today. I'll choose the least expensive one I want for the quality I want, take it home, and my daughter won't see the physician at all.
If I decide that my daughter's condition warrants a physician's visit, I'll call one. The physician will appear on the door, examine my daughter in her bed, and advise me as to what to buy for her condition - and indeed, probably offer me some from the physician's service van.
Physicians, you see, will compete for my business the same as a plumber or other skilled technician. Under such circumstances, it will be in the physician's best business interest to come to my house, to treat my family and I with respect and compassion, and to have a supply of common drugs on hand. There probably won't be much profit in selling the drugs, but as it's inconvenient to run to the drugstore when one has a sick child, the physician may be able to get away with charging more than a drugstore.
A physician in a free society might will even offer to sell other drugs - probably as a side business. "Anything else I can get you as long as I'm here, Mr. Stone? I just got a new shipment of that West River Gold you like. You need any today?"
In fact, in a free society, it won't just be the physicians who make house calls. So will the surgeons. Like other technicians, surgeons will compete for my business. In short order, they'll discover the competitive advantage of offering surgery and recovery services out of patients' bedrooms.
In an anarcho-capitalist society in which individuals self-govern guided by the Non-Aggression Principle, contrast my sinus problem with that of my (hypothetical) grandson:
Firstly, my 17-year-old grandson will probably have the same family physician for most of his life. After all, as long as the care is good and the price is right, having the same individual constantly looking after your body makes at least as much sense as having the same individual looking after, say, your computer network at your business.
Further, my grandson's physician has a good chance of being female. I have a strong preference for female doctors - females have a natural business advantage in terms of bedside manner. Most men have to learn how to appear nurturing.
At the age of 17, during a house call for a persistent cold, my grandson's physician will noticed his deviated septum. She'll make a quick trip out to her van, SUV, or service truck and drag out the CT scanner.
In a free society, medical technology - unhampered by government restrictions - will advance with at least the speed of the personal computer. It will probably advance faster, since people tend to view prolonging their lives as a higher priority than obtaining a competitive business advantage (though in a free society, there will be individuals that attempt to gain competitive advantage in the business of extending human life). Under such conditions, there will be small, handheld or portable CT scanners that would allow a patient to simply lay on their bed for the procedure.
They'll run my grandson through the CT scanner and realize that his physiology - left uncorrected - will result in blocked sinuses, persistent infections, and other nasty problems.
Once the CT scanner confirmed that corrective sinus surgery was the only option, the physician will put in a call to a sinusoidal surgeon - a business associate to whom she'll refer in such cases.
The sinusoidal surgeon will schedule a surgery visit at my daughter and grandson's convenience - and if their convenience didn't match the surgeon's schedule, the physician will call one of the other surgeons competing for my daughter and grandson's business.
On the day of surgery (in all likelihood the next day), my grandson's physician will be present. It's only good business, after all, to assure that your patient feels comfortable with the stranger about to operate on their body. The surgeon will set up a portable surgical environment in my grandson's bedroom, politely asking my daughter to move certain unsterilizable items out of the room for the duration of surgery.
The room and bed themselves will receive the cleaning of their lives, and a portable, sterile flooring placed over the carpet not covered by the bed and furniture.
The surgeon will ask if my grandson wants music, an Internet multicast, or other diversion. When the environment is comfortable for my grandson, he'll climb into bed and the surgeon will administer the necessary anesthesia.
When my grandson wakes up, his room will be exactly as it had been before the surgeon started rearranging things for the procedure - albeit immaculately clean for the first and only time in my daughter's memory. My grandson's physician will remain unobtrusively present for several hours, to monitor his recovery in case of unforeseen complications.
Total cost to my daughter: a few ounces of gold. A little steep, perhaps, but more than worth it in the long term.
By the time my grandson is old enough to worry about his nose sticking out on one side being a problem with girls, the entire concept of hospitals will have been relegated to historical dramas. People will watch movies about hospital stays in the late 20th and early 21st century with the same kind of natural revulsion we experience when we watch the surgery scenes in the movie Glory [http://www.destgulch.com/movies/glory].
However, we won't get there until we stop believing that government can solve the problem. Government is the source of the problem.
Today, we allowing our Federal office-holders and their cronies to violate their oaths of office by passing blatantly Unconstitutional laws. In this case, intervention in the health care industry violates at least the Tenth Amendment [A href="http://www.law.emory.edu/FEDERAL/usconst/amend.html#art-10"> http://www.law.emory.edu/FEDERAL/usconst/amend.html#art-10] - though most of the rest of the Bill of Rights [ http://www.law.emory.edu/FEDERAL/usconst/amend.html] is also impacted.
As long as we allow our elected officials to go unpunished for violating their oath of office, they'll continue to do so. As long as they continue to do so, patients will continue to be treated like cattle.
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