Excerpt from

The Power of Life or Death

by Fabian Tassano

Duckworths, reissued Oxford Forum

It is a truism that in an economic transaction involving the provision of a service for payment the supplier and the consumer have different interests. To begin with, there is a difference of interests with regard to value. The supplier generally wants to provide the least possible and to do so at the highest possible price, while the consumer wants the greatest possible benefit and to pay the minimum price. But there are also more subtle differences of interest. Each party has views about the way the service should be provided, about the appropriate level of quality, and about the rules governing the transaction.

Such differences of interest are often resolved via the mechanism of a competitive market. Competitive markets give each party a certain amount of bargaining power which ensures that the terms of transaction will to some extent reflect each party's interests. A competitive market depends on there being more than one, and preferably many, parties of each type. Choice and the profit motive will then tend to ensure that the benefits of interaction are split relatively evenly between suppliers and consumers. If a supplier tries to arrange a deal with a customer which is biased too far in his own favour, the likelihood is that another supplier will offer a better deal in order to take the business away from his rival. Profit maximisation by competitive suppliers produces benefits for consumers, since suppliers (a) will have a tendency to undercut one another, resulting in lower prices, and (b) will be relatively motivated to reduce costs and so will tend to do things as efficiently as possible.

The economic argument most often cited against a monopoly is that profit maximisation leads it to charge a price for its product which is excessive. However, a situation in which the supplier of a service is not subject to any competition also has other effects. In a more general sense, there is relatively little incentive for suppliers to tailor their services to the precise wishes of their customers. What incentive there is depends on customer demand having some responsiveness to changes in the quality of service provided. If, however, the service provided is an essential one which consumers cannot do without, the responsiveness will be very low, and the incentive of a monopoly supplier to adapt to customer wishes is likely to be minimal.

The insulation from customer wishes of a monopoly supplying an essential service will have two important consequences in addition to the question of price. First, the terms and quality of the service provided are likely to depend almost entirely on the preferences of suppliers. Secondly, the efficiency of the service provided is likely to be poor.

The medical services of industrialised countries have for some time now functioned as quasi-monopolies, in the sense that medical practitioners are subject to minimal competition. This has come about through the creation of a licensing system for the practice of medicine, and through the creation of strong professional associations which include among their objectives the protection of members from market forces, for example by prohibiting advertising. There is therefore a likelihood that the two features of monopoly described above will characterise, at least to some extent, the quality of medical care provided. In other words, we would expect the terms of the service to reflect predominantly the preferences of suppliers, and we might also anticipate the existence of chronic inefficiencies.

With regard to the question of inefficiencies, there is certainly some evidence in favour of the hypothesis that medical services do indeed suffer from a level of carelessness and incompetence considerably worse than that which we might expect given the quantity of resources provided to them. However, it is not easy to assess this aspect of the situation objectively. Medical professions have been careful to protect themselves from scrutiny and criticism. One of the ways this has been achieved is by the creation of an image of the health care worker as one who is necessarily doing his best and whose motives may not be questioned. Another way is by asserting that the work of medical practitioners can only be objectively judged by other practitioners, a claim which has largely been accepted by other professional groups as well as by the lay public.

This book, however, is concerned with the other of the two expected characteristics of medical monopoly. It is to be anticipated that practitioners subject to little or no market pressure will be able to shape the service they offer to suit their own needs, demands and preferences, and that they will gain dominance over their customers. For a service which supplies essential needs, this will give suppliers an extraordinary degree of power.

The central argument of this book is that the powers of the medical profession have grown to unacceptable and dangerous levels. The assumption that doctors and other health care workers act in their clients' best interests has been accepted with a minimum of discussion and has been used to endow doctors with increasing control over their clients. Moreover, the identification of health professionals with moral attributes has led to a belief that doctors may appropriately be charged with the task of making non-clinical decisions on behalf of society, such as whether treatment requested by a person in a specific instance is socially or morally acceptable. Power is, of course, subject to abuse in any profession, and there is no reason to think that doctors are less likely than any other social group to exercise their powers in unacceptable ways. Indeed, it is a hypothesis which should be considered that the control over people's bodies offered by medicine appeals to (among others) people who derive a questionable satisfaction from exercising such control, and that this makes abuse more, not less, likely.

Through a combination of factors, including perhaps a psychological need to believe that those who have control over one are benevolent, the medical profession appears to have become more or less immune from serious criticism. One might think, for example, that the recent revelation that British surgeons are in effect killing their clients by refusing them life-saving operations if they do not give up smoking would have led to immediate demonstrations and a public outcry against the medical profession. Yet, some mild complaints aside, the matter soon disappeared from public attention and seemed to be accepted as simply another feature of life under the National Health Service.

The increasing discretion given to doctors to make decisions and to act as agents of the community, combined with a prevailing world view according to which doctors are moral agents par excellence, is leading to a situation in which doctors are using their position in ways that are anything but ethical. Although the concept of patient autonomy is allegedly being given increasing weight, there is limited evidence for the contention that this is influencing the behaviour of doctors in any way that represents a genuine shift of control in favour of clients. On the other hand, there is plenty of evidence to suggest that doctors' disregard of their clients' wishes is increasing rather than decreasing.

In the first half of this book, we will look at the institutional and ideological setting of modern medicine. We shall examine the attitudes of doctors and their clients to each other, and those of the public to medicine in general; and we shall consider how the current practice of medical authoritarianism has come about, and how it is being maintained.

In the second half, we will focus on specific topics related to edge-of-life medicine. There are three main issues to be considered: individuals being denied life-saving treatment because of decisions made by doctors; individuals being unable to refuse treatment; and individuals being unable actively to end their own lives. There is also the matter of individuals who are unable, or are considered unable, to express their preferences with regard to life or death.