I’ve talked in a number of these essays about the Material Rights that every citizen is entitled to. Food and Housing have each gotten at least an essay a piece. Housing and Technology have been at least briefly addressed. But there is one important piece of the Material Rights puzzle that I have left almost entirely unaddressed: Medical Care. In fact, as I planned out the course of this first volume of essays, I subconsciously left it to be the penultimate essay, just before the one that almost had to finish out the book. Medical care is incredibly complicated. Not only is the science far beyond my personal understanding, but the bioethics are nearly as impenitrable. But medicine is just as important as food and shelter when it comes to a citizen’s right to survival, and so it needs to be addressed here at some point.
Anyone who reads this book should be at the top of the list if dragons turn out to be real and we need to feed them people to appease them.
Yes, that was a non-sequitor. But I’m guessing that although it primarily probably made you puzzled, it also probably made you at least a little bit angry. And there’s an important point to be made there when it comes to the intersection of logic and bioethics. When I define you, the reader, as someone who should be fed to dragons if they exist, I am not actually threatening you in any way. Dragons don’t exist, and apart from young children and fantasy fans with not enough to occupy their minds, no one would take the idea that they ever would remotely seriously. And yet, by telling you that there are circumstances in which I think that you should be fed to a dragon simply because you are a member of a group, i.e. readers of this book, I have made you feel singled out and unappreciated.
In the context of this essay, that doesn’t mean all that much. If you’ve made it this far through the book, you probably have some small appreciation for my ideas (if you’re simply skimming through chapters out of order, shame on you. They’re in the order I wrote them in and if you skip around there will be concepts that haven’t been explained in that particular chapter because I’ve gone over them earlier. I’ve changed my mind, it’s people who read things out of order that ought to be fed to dragons. Now stop dawdling in the footnotes and get back to the main text) but I’m guessing that you aren’t taking my condemnation of you very seriously. On the other hand, if we were to say, for example, that the elderly should be less eligible for medical care because they aren’t going to live as long anyway, that is a much more serious proposal, and that feeling of marginalization that was strong enough in the dragon example suddenly becomes a serious wound. Not only those who are both elderly and in need of medical care would object, but also those who are elderly and not in need of medical care, but who feel devalued just the same. Those who are still young but can anticipate a day in which they might be elderly and would not want to be told that they are not worthy of saving. It creates a massive feeling of uncertainty that does far more harm to the psyche of society than it can possibly make up in seemingly logical distribution of medical resources.
On the other hand, it is a fact that society does not have unlimited medical resources, and there must be decisions made about how those resources are spent. If we accept our three basic premises, that medical resources must be distributed, that all citizens are entitled to medical care, and that creating categories of people who are not entitled to the same level of care as others is unacceptable, how can we walk the line between these three factors to develop a system that works?
The trick here is our definition of medical necessity. Rather than defining who is and is not entitled to care, we choose what care can and cannot be an entitlement. Elective medical treatment, such as cosmetic surgery and treatment for erectile dysfunction, should not only be subject to Consumption charges, those charges should include the fact that they are taking up resources that could be put to medically necessary use. If a patient is getting a laser skin abrasion to remove wrinkles from a dermatologist who could be spending his time checking patients for skin cancer, the Consumption charge for the de-wrinkling should reflect that.
Basically, I imagine a three tiered medical system. At the core, we have genuine medical necessity. This includes all of the treatments we classically think of when we think of medical care. Any care that comes from genuine medical necessity, as reviewed by a panel of three qualified doctors, should not subject the patient to any Consumption charge whatsoever. The next ring out consists of care which is necessary because of voluntary action on the part of the patient: i.e. treating lung cancer caused by smoking. Generally, these sorts of costs are incurred by a small percentage of a larger population. A large portion of the population drinks highly sugary soda, but only a fraction of that group will develop diabetes. For that reason, although the patient did contribute to his own situation, it would be unfair to lay the entire cost of his care on himself. Instead, the cost of his care should be spread among the entire population of those who took the risk. In this case, there would be a Consumption surcharge added to the cost of sugary foods and sodas to cover the cost to society of caring for those who will go on to develop Type II diabetes through their consumption of such foods. Lastly, we have the outer ring of genuinely elective treatment. This includes all non-reconstructive cosmetic surgery, as well as any treatment that has not been demonstrated to be effective. Those who choose to have such treatment will have the full cost of such proceedures added to their Consumption account.
Let’s take a moment to review what exactly we are talking about when we refer to the “cost”. Adam Smith has a great section on this in The Wealth of Nations when he talks about the wages of apothecaries. The reason that medicines prepared by an apothecary are so expensive, he argues, is that they must not only pay for the ingredients, but for the labor involved in making them. And that labor in turn must take into account not only the time that the apothecary spent actually preparing them, but for the time he spent training to be an apothecary. And not only the time he himself trained, but also the time of all those who began training but found themselves not capable of completing it sucessfully. What might seem like a very inflated price for a few powdered leaves (we have to remember that Smith was writing before modern medical science) was actually made up of a large number of very reasonable costs.
Similarly, when we look at the costs of medical treatment in society, there are a number of different components to consider. They can basically be split into three components: medication, which has a high research cost but once discovered is generally fairly simple to produce, doctors, who have a limited amount of time every day and must be very thoroughly trained, and equipment, which is generally expensive both in its research and its production. There are going to be a number of people along the way in an individuals treatment who must be awarded Contribution credit for their efforts, and at some point we must come up with a number for the Consumption charge incurred, whether or not it is ever charged to the patient in question.
Bill has fallen into a hole and broken his arm. (The other characters were tired of him always being brought in to demonstrate consumption and financial sucess and petitioned the author once they found out someone needed to be an example in the medical essay.) He needs to get to a medical center, have the damage to his arm evaluated, and be treated for his injury. First, getting to the medical center. Ambulences are important, and they certainly exist in Imaginary City, but in this case Bill does not necessarily need one. His arm hurts like hell and he needs urgent medical attention, but not at quite a level of urgency that would require paramedics. So instead, he requests Urgent Transportation. This is basically a cross between an ambulence and a taxi cab, in that a vehicle is dispatched to Bill’s location as fast as possible to bring him to the hospital but the driver has no particular medical training. Urgent Transportation is free from Consumption charge and is also available for non-medical emergencies, but once the situation has been calmed the user must be able to justify the emergency nature of his situation to a three citizen panel to avoid a Consumption charge for the trip.
So that gets Bill to the hospital. There he is first seen by a nurse who has been trained in both general nursing and triage. The nurse confirms that his arm does appear to be broken, and sends him for an x-ray. Once his arm has been x-rayed, a doctor who has been trained in orthopedics as well as general medicine will review his x-rays, discuss treatment options with him, and apply a cast. The doctor will then write him a prescription for something to help with the pain, draw up an extended treatment plan including future checkups, removal of the cast, and physical therapy. Depending on the scale of the medical center, Bill may be able to pick up his medication at that time, or it may be sent to him later through the postal system. A nurse will then help him arrange transportation home, and he will go home to get some rest and wonder just how such a narratively convenient hole would up in his backyard without him noticing it.
That’s the process, but what about Contribution and Consumption? Bill’s arm has required the attention of two nurses, one doctor, and one x-ray technician, as well as taking up time on the x-ray machine. The key to establishing a system for rewarding medical staff and estimating the cost of an illness or injury is thinking in shifts. We mentioned in the essay on land use that every district should have a local medical center, and that there should be at least one comprehensive medical center for every four urban districts. The shifts available at each such medical center will vary depending on the local population and its medical needs, but in general a local medical center should be staffed sufficiently at all times to deal with the primary care needs of the citizens in its district, and a Comprehensive medical center should be able to deal with the specialty and emergency medical needs of the city it is in and the surrounding area. Exactly how many doctors in each specialty need to be on duty at any given time for that need to be met is something that the community of physicians will need to decide for themselves through trial and error.
So rather than earning Contribution credit based on the number of patients they treat, or the number of tests they perform, doctors and nurses recieve their Contribution credit based on the shifts that they sign up for. Let’s say that a local medical center generally requires 8 primary care physicians and 15 nurses on duty between 8am and 6pm, and two primary care physicians and three nurses on duty overnight. The SNA system will automatically create those shifts and list them as available, and doctors and nurses will be able to sign up for them. As with all other SNA positions, the longer they sit unclaimed the higher the Contribution credit for them will go, and the more people who try to sign up for the same timeslot, the lower the Contribution credit for them will go. Once they are signed up for a shift, doctors and nurses have the responsibility to ensure that all patients who come to the medical center during their shift recieve adequate medical care. The Consumption cost of a visit is based on the Contribution credit the doctor or nurse recieved for their shift and the percentage of that shift taken up by the visit in question.
Now let’s look at equipment, for example the x-ray machine used to evaluate Bill’s arm. Equipment also acts in shifts, but unlike human labor an x-ray machine can work 24/7. Nearly all local medical centers would need an x-ray machine, and Comprehensive centers would likely need two or three. This means that a number of such equipment “shifts” would be available, and if suffient equipment was not available to fill those shifts they could become quite valuable. An x-ray machine obviously cannot earn Contribution credit, but its designer can, and the calculation is necessary to determine it’s contribution to the total cost of Bill’s injury.
Once all of these factors have been totaled up and the cost of Bill’s injury is known, the next step is determining who is required to pay that cost. If Bill fell into the hole because Greg in his continuing role as the villian of the piece set a trap for him, that Consumption cost would be charged to Greg. If Bill deliberately broke his own arm because casts were trendy that season, the Consumption charge would be made to Bill. If he fell into the hole because he was drunk, it would be added to the pool of expenses caused by alcohol, as discussed in the chapter on social vices. But if it was simply an accident and there is no one to blame, as is often the case, there would be no Consumption charge to anyone, and Bill would be able to go on his merry way.