Treating the Least Well Off

In Reply: Dr. Phillips is entirely correct that the international trend toward using market mechanisms in an effort to increase value for money in health care arises from an ethical vision. That vision, ultimately derived from Adam Smith, postulates that the invisible hand of the market will reliably enhance various human goods and stigmatizes governmental action as "coercive intrusion."

I am afraid, however, that (in his words), Dr. Phillips is "ignorant or arrogant" in not acknowledging that the view he advances of the superiority of markets and the inevitable harm caused by government interference is a hypothesis, not an established truth. The social experiment that the U.S. and other countries have embarked upon may ultimately demonstrate that market forces can be harnessed to improve the safety-net services that historically have been provided by religious bodies and other forms of community action. For now, however, market-based health care rests on a hypothesis, not a proven truth.

Having practiced since 1975 in a not-for-profit capitated group practice, I have seen firsthand many positive impacts of market competition. However, the limited data to date about the public backlash against managed care suggest that the public regards health care as a social good, not a "commodity" (1).

I will decline Dr. Phillips's invitation to attack the ethics of the marketplace. Improved policy and service delivery require data and reflection, not attack and counterattack. In a previous column about for-profit health care, I criticized the way clinicians and professional associations attack for-profit health care as prima facie unethical (2). That form of attack without data will not and should not influence policy makers. Similarly, a faith-based but data-free attack on public programs cannot provide a sound basis for rational policy.