Treating Health Care as a Commons

From my reading of history, medical care was once a more intimate and ethical endeavor, a calling that involved a respectful communion between doctor and patient. However, in recent decades, at least in the United States, it is clear that medical care has become a technology-driven market transaction. Doctors who were once skilled at seeing illness in the context of the “whole person” are more likely, in today’s environment, to know how to rush patients through 15-minute assembly-line appointments and game the insurance/Medicare system with the right billing codes.

Paradoxically enough, a system that ostensibly aims to improve efficiency has resulted in soaring costs. As health care has become more of a market service, and less of a professional calling, Big Pharma, hospitals, insurance companies and medical device makers have become the masters of the system, with each jostling for a piece of the action. It is now standard practice for companies to offer gifts and junkets to doctors — all in the name of improved health care, of course — and to market new diseases, technologies, treatments and so forth. The goal, in short, is to “grow the market,” not necessarily to make people healthier.

Could the commons hold some answers?

Amazingly, two doctors writing in the Journal of the American Medical Association (JAMA) seem to think so. Drs. Christine K. Cassel of the American Board of Internal Medicine and Troyen E. Brennan, a medical doctor and lawyer with Aetna, suggest that the commons may offer some distinct advantages over the fee-for-service model that now prevails in U.S. medicine. Their article in the June 13, 2007 issue of JAMA, “Managing Medical Resources: Return to the Commons?” argues that “physician engagement in a medical commons, ideally with communities of consumers, is arguably the only approach that will ensure proper allocation of health care resources.” (The article is locked behind the JAMA paywall; those with access can find it at JAMA, vol. 297, no. 22, pp. 2518-2520. A tip of the hat to Julie Ristau, who brought this article to my attention!)

Cassell and Brennan start with the hoary “tragedy of the commons” paradigm, arguing that individual physicians cannot (and ethically should not) set limits on the utilization of medical resources for a given patient. “Society” must therefore “establish a global budget for health care or guidelines for utilization,” the authors argue.

The problem with the current system, the authors argue, is that individual physicians cannot assert their moral agency for health care choices by participating in a commons. Any money that doctors might save through “bedside rationing” would be siphoned away by insurance companies and hospitals, and would not necessarily be used to improve patient care. Individual doctors therefore have little incentive to keep a lid on costs or make ethical judgments because those choices have been taken away from them. They have no “community responsibility” for aggregate costs or outcomes.

Cassel and Brennan write that “except in prepaid group practices, there is no explicit commons that would link the moral duty to individual patients with responsibility to a community, and the moral duties [of physicians] remain exhortations….” There is no way for physicians to assess the impact that their decisions have on the larger community of patients or even their own health care institutions. They are treated as cogs in the machine, not as moral agents whose caring and ingenuity might be harnessed to individualize treatment or improve overall outcomes.

“How could physicians be engaged in ways that patients would trust?” ask Cassel and Brennan. Their answer: “The commons must be reconstructed through organizational change…. [A] broader community focus and a shared responsibility are needed to build the ethical base for clinician management of health care resources.”

The authors acknowledge that this vision may seem far-fetched, in part because health care tends to be scattered among so many different providers, insurers. drug companies, labs and other vendors. Medical care is a marketplace, not anything resembling a commons. But Cassel and Brennan ingeniously suggest the creation of “virtual commons mechanisms” to encourage physicians to operate within a framework of “group responsibility.” They cite some specific systems — one is an “accountable care organization” — in which multispecialty physician groups and small practices affiliate with a hospital to serve a defined community of patients for whom they assume responsibility.

Such a virtual commons in medical care could create “a sound ethical framework for effective resource management linked to high-quality care.” It would limit cost shifting, take responsibility for all the care of a population, focus on public health and prevention, and move away from a per-unit reimbursement system for services.

The authors acknowledge that establishing a commons for medical care would be a “tall order,” but they also bluntly ask, “Is there a professional responsibility to establish the commons?” They note that “market-based and regulatory approaches place the welfare of patients in hands other than those who provide medical care.” This means that the allocation of resources occurs without the “caring, commitment, clinical experience and wisdom of experience that clinicians bring.”

Physicians have seen the medical commons enclosed, leaving them to toil as wage-slaves in the health care marketplace. Yet physicians could enjoy multiple benefits from reclaiming their profession as a commons. While they would have to shoulder new responsibilities — especially in deciding how to allocate scarce resources fairly and ethically — they would regain their moral agency and a considerable measure of their ethical standing.

Whatever challenges this would pose, it would be a huge improvement over letting insurance company bureaucrats dictate treatment from their office cubicles. A medical care commons would revamp the marketplace model that now prevails by establishing a physician-driven model based on clinical medical judgments and community needs and outcomes, not market-driven efficiencies. A commons could make it easier for physicians to make better, more ethical judgments; for patients to get more appropriate and cheaper care; and for both to have more trusting, constructive relationships with each other.

It is hard to assess the feasibility of Cassel and Brennan’s vision because their article is fairly short and elliptical. Still, their analysis is compelling. The bigger problem would be how to actualize a new commons-based system of medical care. It would entail major re-alignments of power and disrupt many entrenched and lucrative medical practices. Yet there is little doubt that a commons for medical resources would be more humane and ethical than our current system. It could also reduce medical costs because the fierce incentives to maximize profits would be mitigated or spread across more parties. What’s not to like?

Originally published by David Bollier at under a Creative Commons Attribution license.