From Trust to Political Power: Interest Groups, Public Choice, and Health Care

In 1963 Kenneth Arrow offered a simple empirical observation that suggested a core impediment to the effective functioning of market arrangements in health care. "Because medical knowledge is so complicated," he noted, "the information possessed by the physician as to the consequences and possibilities of treatment is very much greater than that of the patient, or at least it is so believed by both parties" (951). According to Arrow, however, society found a way to manage this information asymmetry that would otherwise leave people vulnerable to suboptimal decision making and exploitation by the suppliers of medical services. "Delegation and trust are the social institutions designed to obviate the problem of informational inequality" (966).

According to this reasoning, we make efficacious choices by permitting our physicians to both define the choice set of the various treatment options and weight their expected values. We feel comfortable delegating a significant chunk of our decision-making sovereignty regarding medical care because of the trust we have in our physicians. But in Arrow's framework, why does this dyadic trust emerge in which we place such faith, given the lack of a formal instrument for insuring against a failure to benefit from medical care? Not primarily because as individuals our physicians are gracious, or benevolent, or even just plain smart, although those characteristics may be relevant. We trust our physicians in this dyadic relationship because of a collective or social attribute we recognize in them, that is, a "generalized belief in the ability of the physician" predicated on his or her formally prescribed, scientifically grounded professional training and license to practice medicine in accordance with the standards of the profession (965). Indeed, should someone fall ill, say, at a public gathering, the general call goes out for "a doctor" and the individuals who may be lending immediate comfort yield without question to the entirely unknown woman or man who appears and establishes this professional link by stating simply "I'm a doctor" and proceeds to treat the patient.

Other essays in this volume explore, and often question, the reliability of individuals granting such inclusive trust to physicians to guide their personal medical care, especially as we know more about what "the doctor" does not know while social and technological change have evened the informational scales at least a bit. I examine a broader consequence of physicians' claims of knowledge and trust that Arrow minimized in his analysis but that have had profound implications for the organization, financing, and delivery of health care services as they are experienced by the nation as a whole. Based on the same claims to science and knowledge that medicine has used to invite our dyadic trust in physicians at the individual level, the medical profession has long sought, and often obtained, broad-based social trust in its leadership of health care policy making by local, state, and federal governments. Organized medicine has sought to dominate the politics and policy of health care by arguing that only it as a profession has the understanding of science and practice necessary to construct optimal social arrangements for providing access to care. Until the legitimacy of this exclusive claim was successfully disputed, starting primarily in the 1970s, and other groups developed the organizational wherewithal and informational capacity to call into question the social trust that physicians had enjoyed, the medical profession, with the rhetoric of commitment to the public good, had employed its trust-based political leverage to extend and protect its economic self-interest. This essay is about the negative social consequences of trust in physicians, which Arrow did not adequately anticipate given his focus on the dyadic form of trust, and how the social role of physicians has changed in the ensuing decades.

Trust and Delegation as Political Power

Professions gain respect and their members garner both dyadic and...