Medicine and the Market: Equity vs. Choice (review)

Commodities are dreamed up, financed, constructed, advertised, desired, sold, and bought in ways sensitive to the pressures of "the market"—or rather, of various and variously distorted markets. There's much to lament about this, in my view, but there seems no realistically attainable, clearly superior alternative arrangement.

Despite the pervasiveness of the market, people continue to think that there are some things that should not be configured as commodities—our bodies, ourselves, our votes. We block efforts to buy and sell people, or their nonrenewable parts, or their sexuality, or their exercise of the franchise. What's trickier to explain is how goods and services for which money is demanded and by which large incomes are realized can be preserved from becoming commodities, and why we should want them to be so preserved. The market, after all, is famous—or, anyway, famously lauded—for its efficiency in detecting and servicing human needs and wants, and for doing so in a way that allows people to choose and thus to express their values freely.

Yet in the teeth of the enthusiasm for markets that has been such a particularly prominent feature of the last three decades, societies throughout the world have been tolerably successful at keeping a very expensive, wealth-producing industry—medicine—from becoming wholly commodified. Daniel Callahan and Angela A. Wasunna do a superb job at providing a series of views of how health care is financed and distributed in a variety of countries: Canada and the United States in detail, but at different degrees of resolution; several countries of the European Union; and developed and developing countries in Asia, Africa, and South America. From these studies, they conclude that the market as such is poorly suited to enhance in any substantial way the availability, quality, or affordability of health care services. While various market-like features, experimentally and judiciously applied, might have something to contribute to sustainable systems providing decent health care to entire populations, there are neither good instrumental nor in principle reasons for the world to retreat from what is apparently a widely distributed and stubbornly rooted disinclination to treat medicine as we do cars, TVs, or other such widgets. Indeed, the United States has no sufficiently good reason to resist this near consensus—that is, to resist the influence of the market on medicine and to make access to a decent package of health care benefits less a matter of what one can purchase privately or enjoy as an employment benefit, and more a matter of a right of citizenship.

Callahan and Wasunna succeed admirably in making a powerful case for this general view. They have written an accessible, engaging book that provides readers with both general overviews and detailed discussions of health care as it is paid for and provided in many countries and cultures, testifying to the remarkable resilience of the conviction that medicine ought not to be treated wholly or even primarily as a commodity, and detailing the damage caused when either external or internal pressures force a society away from that course. One of the book's most telling examples is the damage to African health care systems caused by the privatization-prone policies of the International Monetary Fund and the World Bank.

Their overall case is all the more plausible because they resist idealizing either private or public methods of health care provision, comparing real (and therefore flawed) markets against real (and therefore flawed) government-guided systems. Providing a basis for realistic comparisons is an important achievement. The vigorous discussion of health care provision and financing that is once again taking place in the United States ought to reflect careful and respectful attention to the rest of the world's experience; any claims about "American exceptionalism" in this regard should be much more convincingly motivated if they aren't to be met with the deepest skepticism. Making American health care fairer, better, and sustainable will require freeing ourselves of the...