Anatomy and Atrophy of Medical Paternalism

Medical paternalism—the idea that patients should defer to the intrinsically superior knowledge of physicians in all matters related to health—has been conventional wisdom for millennia. However, modern advances in information technology are narrowing the information gap between patients and doctors, threatening to scramble age-old assumptions about how care should be delivered.

Senior Research Fellow Robert F. Graboyes of the Mercatus Center at George Mason University and Professor of Genomics Eric Topol of the Scripps Research Institute review the history of medical paternalism. In particular, they examine the ways in which new technologies are rapidly eroding the physician’s privileged role by deconstructing, digitizing, and democratizing medical knowledge. The study finds that these new technologies offer unprecedented opportunities to save lives, reduce sickness, and ease pain, and it provides policy suggestions for easing the healthcare industry through the coming revolution.

HISTORY OF PATERNALISM

Originally a democratically crowdsourced endeavor, medical care has long been the purview of licensed physicians who claim supremacy over their less informed patients.

• The fact that medical practice probably did patients more harm than good before the 20th century did not prevent a proliferation of medical regulations, including medical licensure, scope-of-practice limits, FDA regulation, and certificate-of-need laws.
• Rapid medical advances in the 20th century strengthened the case for paternalism, since the general public could not keep abreast of increasingly complex medical knowledge.
• Modern paternalism is enforced primarily via three mechanisms: governmental powers such as the FDA and Medicare, private entities such as medical societies and boards, and social conventions that constrain the behavior of doctors and patients.

The current paternalistic regime carries serious costs, however:

• Restrictions on supply. Certificate-of-need laws limit the number of hospitals and the services they may offer, scope-of-practice laws limit nonphysician providers’ ability to practice up to the limits of their training, telemedicine restrictions impede medical practitioners’ ability to deliver care remotely, and medical licensure limits the number of physicians.
• Restrictions on innovation. The FDA increases the cost and unpredictability of the development process for new drugs and devices, slowing or eliminating not only current advances but also associated innovations that would have followed them.
• A suboptimal mix of expenditures. Mandatory health insurance coverage shifts aggregate spending toward health care, while Medicare pricing and other price controls likely skew the mix of goods and services that make up the healthcare sector.

DECLINE OF PATERNALISM

Since 1990 the pace of technological innovation has far outstripped the evolution in health care, with technology reducing the information gap between patients and physicians. This revolution in technology is returning medicine to its democratic roots.

• Previously, patients were largely ignorant of medical care while physicians invested heavily in acquiring knowledge about the topic, but the information gap has shrunk considerably as information technology has empowered patients.
• Innovations in health care are arguably proceeding too quickly for regulators to maintain their grip. While it is fairly inexpensive to regulate the use of large and costly MRI machines, the same is not true for widely distributed smartphone apps and do-it-yourself devices.
• New services allow patients to take control of their health care. Telemedicine allows patients to decide when and where to see doctors, and web-based companies are performing services as diverse as eyeglass refraction tests and genetic tests.
• Smartphone applications can provide electrocardiograms, diagnose skin lesions and rashes, and diagnose ear infections. They can also test for cholesterol, inflammation, vitamin D deficiency, fertility, sperm count, and more.
• The Internet offers patients and providers new ways of aggregating varied sources of information. For instance, medical crowdsourcing brings together individuals with rare conditions so they can share information, compare notes, and help educate their own physicians.

CONCLUSION

While democratized medicine may be a difficult notion to accept in a world so accustomed to paternalism, the medical landscape is changing quickly and the question is how, not whether, to adjust to the changes. The following policy recommendations would help expedite this transition:

• Reconfigure Medicare reimbursements. Medicare pricing skews health care toward costly and excessively risk-averse practices, and it should be reformed.
• Reform drug and device approvals. The FDA’s excessively costly and lengthy approval process needs to be reformed. The agency should allow patients to access preapproval drugs and devices, and it should reduce its interference with medical device innovation and focus on safety over efficacy.
• Allow medical institutions greater flexibility. Certificate-of-need laws and restrictions on the corporate practice of medicine should be rolled back to allow more rapid innovation.
• Loosen constraints on healthcare providers. Lawmakers should reduce barriers such as medical licensure and scope-of-practice and telemedicine limitations.
• Permit greater variation in medical education. The United States’ centralized medical education system should be replaced by cross-disciplinary programs with more varied design.