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THE GRAND INQUISITOR AND THE ROLE OF THE STATE IN MEDICAL ECONOMICS JANE M. ORIENT* Jane M. Orient is in the private practice of medicine in Tucson, Arizona, the city of her birth. She returned there after receiving her M.D. degree in 1974 from Columbia College of Physicians and Surgeons, and an internship and residency at the University of Texas Health Sciences Center at Dallas. After spending almost 4 years as a staff physician in the Ambulatory Care Section of the Veterans Administration Medical Center in Tucson, she decided on "solo" practice, while maintaining an appointment as adjunct assistant professor of internal medicine at the University of Arizona College of Medicine . She writes, "My experience in the public sector, encompassing Harlem, Delafield, and Roosevelt Hospitals in New York City, and Parkland Memorial and the V.A. in Dallas, inspired me to invite a prominent author of health legislation to spend a shift with me as Parkland Pit Boss. He declined, and stopped answering my letters. Participation in a V.A. research project involving algorithms as a method of controlling costs of health care piqued my interest in the dismal science of economics. Renewing my acquaintance with the Grand Inquisitor in preparation for a Sunday school lesson was the seed crystal that precipitated this essay." [The Inquisitor and his Church have] at last vanquished freedom. . . . Now, for thefirst time it has become possible to think of the happiness of men.—Dostoevski, "The Grand Inquisitor," The Brothers Karamazov To divert attention from the question of the truth or falsehood of an idea, the accusation of simplemindedness is an effective device. The *Address: 3615 East Fifth Street, Tucson, Arizona 85716.© 1981 by The University of Chicago. All rights reserved 003 1-5982/82/250 1 -0256$0 1 .00 20 I Jane M. Orient ¦ The State andMedicalEconomics sophisticated scorn platitudes, deceived by their appearance of triviality. All of Euclid's geometry was erected upon five postulates, seemingly so obvious as to be beyond dispute. Only centuries later did mathematicians think to defy the Fifth Postulate and create whole new geometries, with theorems contradicting those of Euclid. Likewise, discussions about economics , the science of human action, must rest on certain assumptions about the nature of man. A change in the premises will result in a radically different economic theory. In contrast to mathematical discourses , writings on economic questions such as health policy seldom make the assumptions explicit but leave them to be inferred from the conclusions. Whether the authors believe in their axioms, with their inexorable consequences, or are just too preoccupied with complexities to be conscious of their foundations cannot always be determined. Two Visions of the Nature ofMan Two fundamentally contradictory belief systems about the nature of man are currently at war: the one that inspired the American Revolution , and the one espoused by Marxist revolutionaries. The "moderate" position is a schizophrenic one, which expresses some thoughts borrowed from each, despite their logical inconsistency. Western tradition, grounded in a Judeo-Christian heritage, holds that the individual is sacred. In Kant's formulation, every man is to be treated as an end in himself, never as a means only. He is a creature with freedom and dignity, responsible for the consequences of his own actions . While eloquently expressed by Western thinkers, the idea of individual liberty is not original with them but is rooted in Jewish history, embodied in the ritual of the Day of Atonement when each man must account for what he has done without reference to those who either helped or corrupted him. Because of his freedom, mankind is not perfectible ; he can, and often does, choose evil. The bold experimenters in America proclaimed that each individual is endowed by a higher authority with inalienable rights to life, liberty, and property. He has the right to pursue happiness (which naturally requires a minimum economic well-being) but has no guarantee of success, because in classical economic theory, scarcity is decreed by nature. Wealth must be wrested from the earth with sweat and ingenuity, and the producer is entitled to the fruits of his labor. Private property, rightfully acquired by investing what is earned, is essential to assure control over...


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