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This page created April 2000 by Michael Wynne
This page examines the regulatory role of
professional values and ethics when contrasted with the ethic of the
marketplace.
Regulation:- Regulations prohibit, limit, control and prescribe specified conduct. There is no inherent pressure in the marketplace to ensure and even encourage competitors to comply with regulation. In the health care marketplace intense competitive pressures for profit exert strong pressures to overservice in one context (eg Tenet/NME) and to deny care in others (eg Managed care). In all market contexts there are strong pressures to understaff and to provide less costly and often inferior care. There is also pressure to do more work than can safely be provided in the available time. An excessive and uninformed drive for efficiency can compound this problem. Because patients are not competent customers motivation towards providing good care is limited. There are consequently very strong pressures to ignore, subvert or even deliberately defraud.
Professionalism as regulator:- In the marketplace adequate care is dependent on professionalism, on surveillance, on detection, and on prosecution of failures. Competition theorist's see professionalism as anticompetitive and self serving. Their attack on professionalism shows that it is undervalued. Because marketplace thinking devalues the ethic on which professionalism depends, professionalism is increasingly rendered ineffective by marketplace theory. Criticisms of professionalism become self fulfilling.
The other restraints on poor practice and exploitative practices assume that surveillance can adequately reflect what is happening in a complex sphere of activity and that penalties actually act as a deterrent. These assumptions are not supported by the facts in the marketplace. This will be addressed elsewhere on this www site.
Professionalism and Competition:- The threat to patient care posed by strong financial pressures has been recognised among the professions for many generations - for over 2000 years. For this reason society has allowed the professions to control competition and establish codes and domains where limited competition is permitted.
Professionalism and Society:- Professionalism is a fragile social structure and very vulnerable. It gains its legitimacy not only from history but from the reinforcement it receives from society. It is profoundly influenced by the society in which it operates. It has certainly bent before the winds of social pressure in many societies and I do not want to defend many things that have happened. I would argue strongly that when compared with the adverse outcomes of the health care marketplace in the USA its failures pale into insignificance.
David Malouf :::: Personality and the marketplace:- Almost all of the pressures in the healthcare marketplace are away from care. The very arguments which give the marketplace legitimacy threaten care. They foster exploitation of the weakness of others and distrust. Even the Australian author David Malouf hints at this in his 1998 Boyer lectures. He suggests that the things "that go to the making of a successful criminal - entrepreneurial egotism, an eye for the main chance and for the weakness of others -- may be the same qualities that in other circumstances make a politician or businessman".
The US health care marketplace provides ample confirmation of Malouf's views. The sort of people Malouf describes are not the sort of people any of us would select to care for the sick and aged. The consequence is revealed in the US marketplace. We would not expect the sort of people we would select to care for the sick and aged to have characteristics which would make them successful businessmen. It is hardly surprising that not for profit corporations, teaching hospitals and groups of doctors have not done well in the marketplace.
Correcting Dysfunction:- In the market ethic there is little trend or pressure towards self correction. Both financial success and failure encourage further dysfunctional behaviour. In professionalism the legitimacy and theoretical underpinning is towards care and concern for others. While there are many slips from grace there are constant pressures towards correction. These do not exist in marketplace thinking. There is a long history of market failures to learn from.
My argument here is not that there should be no transparency and accountability or that there should be no regulation or oversight, but that these should be built around and be supportive of professionalism. These processes cannot address the nuances of daily life. They are the fall back position.
CLICK HERE -- to examine the failure of regulation in the USA.
CLICK HERE -- to examine the failure of regulation in Australia.