June 28, 2000
'Fair' Health Care Isn't Always Best
By Theodore Dalrymple. Theodore Dalrymple is the pen name of Anthony Daniels, a British physician and contributing editor of City Journal.
Every child loves a list: the largest countries in the world, the longest rivers, the highest mountains. Now, thanks to a new World Health Organization report issued last week, every child will be able to learn a list of the best health-care systems in the world. France comes in at the very top of the list, while Sierra Leone falls last at 191st place.
As for the U.S., only a child with quite a good memory will be able to get that far. America falls 37th on the list, just below Costa Rica but just above Slovenia, and fully 15 places below Colombia.
Admittedly, some of the countries listed ahead of the U.S. are rather small and unimportant: Malta, Luxembourg, Monaco, Andorra and San Marino. But a list is a list: You can't learn the periodic table by omitting chemical elements that are rare geologically and unimportant economically.
The problem with a list of the kind compiled by the WHO is that, once it exists, it is almost impossible to liberate minds from the prejudice that it must mean something. In other words, there must be some indubitable feature of reality to which it corresponds. For surely no one would go to such great lengths to decide how many angels may dance on the head of a pin -- and then list them in order of precedence -- if it didn't hold some meaning.
It is true that health care is far better in Norway than in the Central African Republic, and to that extent the list corresponds to reality. But we hardly needed people who are paid large salaries in Swiss francs to tell us so, after years of close and no doubt expensive attention to the question.
It is when one learns of the superiority of the health-care system in Colombia to that in the U.S. that one begins to blink in disbelief. Does this mean that it would be better to fall ill in Colombia than in the U.S.? No, it does not. Does it mean that people live longer and healthier lives in Colombia than in America? No, it does not.
What it does mean is difficult to say. The WHO has based its league table on an amalgam of life expectancy, freedom to choose one's doctor, application of preventive medicine, and fairness of the way in which health care is financed and delivered.
Fairness is, as one might expect, of crucial importance for the WHO. By fairness the group means equality in every phase of health care except in the way it is financed. When it comes to money, the WHO believes the burden of paying for health care must fall more heavily upon the rich than upon the poor.
Once this principle is conceded within a society, the way is open to extend it between societies, all men having been created equal. Isn't it incumbent upon rich countries, therefore, to pay for the equal health care of the poor? And who, do you suppose, will administer the vastly increased health budget of the whole world? Why, the compilers of the report, of course.
Let us examine this WHO-type fairness by means of a little thought experiment. Imagine two societies, both with 20,000 people who will die without a heart operation. In one society no such operations are done; in the second, 10,000 are performed on the half of the population that is most able to pay for them. Which society has the better health-care system?
From the fairness point of view, the former system, in which everyone died prematurely, is clearly superior. But it would surely be an odd person who preferred a system in which everyone died prematurely to one in which only half the susceptible people did. Within quite wide limits, fairness isn't an important feature of a health-care system, and shouldn't be used to make comparisons between them.
A patient wants to be well-treated. It is no consolation to him, on receiving inferior treatment, that everyone else receives poor attention too. For each individual, the absolute worth of what he receives is vastly more important than the relative.
Moreover, absolute fairness is a quality that is inimical to medical progress and innovation. This is because new (and usually expensive) methods are impossible to introduce simultaneously everywhere and equally. As well, if financial advantage isn't the only motive for technological innovation, it is certainly a very strong one. It is no accident that medical innovation is by far the most rapid in the U.S., with its unfair system.
The WHO admits that the U.S. health-care system is the most responsive in the world to the wishes of individual patients. That it nevertheless achieves only 37th in overall ranking lays bare the strongly dirigiste instincts of the WHO. It seems that neither the people of the U.S. nor their doctors really know what is best for them, and need the WHO to tell them.
On a recent trip to Colombia, I read a number of Colombian periodicals. I noticed many advertisements for health-care facilities in the U.S. On a recent trip to the U.S., I read a number of American periodicals. I didn't notice a single advertisement for health-care facilities in Colombia. Isn't it curious that people are prepared to travel long distances and spend large sums to be treated by a worse health-care system than the one they have at home?
interactive.wsj.com |
