Bioethics emerged in the 1960s from a conviction that physicians and researchers needed the guidance of philosophers in handling the issues raised by technological advances in medicine. In this book, Tom Koch argues that bioethics has failed to deliver on its promises and has promoted a view of medicine as a commodity whose delivery is predicated not on care but on economic efficiency. Edward Larkin thinks Koch provides an interesting history of the field, but he unnecessarily blames bioethicists for recent developments in health care and medicine.
Thieves of Virtue: When Bioethics Stole Medicine. Tom Koch. MIT Press. September 2012.
Tom Koch’s book, Thieves of Virtue: When Bioethics Stole Medicine immediately demands a few questions from the prospective reader. First, why choose to say “when bioethics stole medicine?”. Why not “how bioethics stole medicine,” or “why“? Second, what exactly does it mean to “steal” medicine? Koch quickly addresses this choice and posits that by imposing an artificial narrative of scarcity, 20th century bioethics has replaced the age-old ethics of medicine embodied in the Hippocratic Oath (first, do no harm) with its own inadequate moral codes.
Wait…artificial narrative of scarcity? The United States currently spends about 18% of GDP on health care. Other countries, like the UK, spend a more manageable 10% of GDP on health care, but costs are rapidly rising with no signs of abatement. Most economists consider this level of spending to be wasteful and inefficient. A minority of economists have argued cogently and compellingly that 18% of GDP is not necessarily inefficient, and that the US gets good value for its spending. Almost none, however, would claim that there is room to increase spending, and that scarcity is artificial.
Koch claims that bioethics has persuaded people that resources are scarce, and therefore should be apportioned by valid ethical criteria (devised, of course, by bioethicists themselves), and that in doing so, they are advancing a neoliberal, individualistic agenda. In my experience, I have found this couldn’t be farther from the truth. Bioethics usually advances the exact opposite philosophy. Bioethicists object to market allocations of medical resources, which are apportioned based on ability and willingness to pay. Bioethicists also tend to advocate alternative distributions, like giving treatments first to the youngest in a group, or to those that will fare best from the treatment, or to those who add the most ‘utility’ to society. Of course there is talk of scarcity, but if Koch’s issue with scarcity is better placed with economists than bioethicists, since scarcity has been one of the central tenets of economics since the days of Adam Smith.
Koch also bemoans the loss of paternalism in medicine – the ‘good old days’ when patients listened to doctors. That paternalism in medicine has declined is uncontroversial. However, in praxis, doctors still dictate most treatment decisions. Whether patients actually are more participatory than they have been at the past, or simply fashion themselves more participatory, is an interesting and unanswered question. But is the loss of paternalism the fault of bioethics as Koch suggests? Maybe this is best answered by asking another question — why was medicine paternalistic in the first place? We don’t necessarily trust investment managers with our money, car dealers with our automotive interests, or real estate agents with the task of finding the best house at the best price. Why then do we trust doctors?
About 50 years ago, the Nobel prize-winning economist Kenneth Arrow attempted to answer this question in his famous article, “Uncertainty and the Welfare Economics of Medical Care”. Arrow asserted that because it is hard to verify whether doctors make good decisions, our culture has created an ethic of trust and duty. If a stock broker consistently achieves low return on your money, you might end of firing this person. If a surgeon fails your knee surgery, firing him or her isn’t likely to yield an optimal result as your knee is already injured. Instead, we put in place licensure restrictions and enter into a trust relationship with physicians. Koch claims that bioethics changed this through its sustained attack on physicians as arrogant and self-interested. But in seeking to exonerate physicians, Koch seems to portray bioethicists the arrogant and self-interested ones. If there’s any lesson to be taken from the entire situation, it is that nuance is needed in categorising entire classes of people, whether they be physicians or bioethicists. Koch unfortunately does not provide that.
Are there other explanations for why the physician is no longer the faultless, noble figure he or she once was? A more benign explanation is that access to information has improved significantly – through advances like the internet, and also consumer ratings – and this allow us to judge doctors based on performance, and therefore we don’t need to trust them as much as we once did. Fifty years ago, when someone wanted a knee surgery, they were likely to rely on word of mouth and/or hospital reputation. These days, health consumers are beginning to use actual data to make these decisions. As the data becomes more user-friendly, these trends might increase, and our inherent trust in doctors will continue to decline apace. We might briefly mourn the degeneration of the cultural pact between doctors and patients, but it might actually be a positive development. For all the good that trust entails, it can also seriously decrease competition. If the medical system responds to this new normal by improving quality (as economic theory would suggest), this trade-off may then prove more valuable than the loss of trust.
In the end, Koch provides an interesting history of bioethics, but his overall argument unnecessarily blames bioethicists for recent developments in health care and medicine. While bioethicists may have played some role in emphasising scarcity rather than individual patient care in medicine, it was certainly not solely their doing. Indeed, changing economic realities (health care costs) and a more sophisticated understanding of which procedures work and which do not, have spurred many to consider the health care system as a whole rather than individual patient-doctor interactions. And while “economic efficiency” might seem a cold and antiseptic phrase when applied to health care, insofar as it strives to maximize outcomes at minimal costs, I would argue that it is something to be lauded rather than deplored.
Edward Larkin is a medical student at the University of Pennsylvania. He studied for an MSc in International Health Policy at the LSE in 2011-12, where his dissertation investigated the relationship between uncertainty and technological change in health care. He graduated from the University of Notre Dame as valedictorian in 2011, studying biology and classics. Interested in the intersection of science, technology, and society, Edward has worked in wireless health care and at the UK Department of Health, as well as in basic science laboratories. Read more reviews by Edward.
It is not, I think, that Koch seeks a return to the old days of physician paternalism. Rather it is that he argues there was always negotiation between doctors and patients. The charge of rampant paternalism was unfair and, today, contra Mr. Larkin’s experience, the literature suggests bioethicists are the ones who seek to make judgments irrespective of patient choices. Certainly, a suite of legal cases makes this clear.
And, too, the scarcity argument in this work is fundamental. The US may spend 18% of GDP on healthcare. And in doing so it has excluded over 40 million persons. The problem is not necessarily lack of money but the system of healthcare itself, he suggests. And here there are others in agreement.
It is always chance to categorize groups. But the whole is based on the literature, as well as experience, and there there seems to be a broad pattern in which the portrayal and argument are accurate. So, too, is the emphasis in theory but not in practice on the role of those trained in moral philosophy but not in medicine as medical arbiters.