In an era where people marry AI chatbots, online markets allow people to place bets on when the US will bomb another country, and wealthy individuals and corporations openly purchase political power, it is perhaps time to reconsider the old adage “money can’t buy everything.” As I wrote in my previous blog, Michael Sandel describes in his book What Money Can’t Buy: The Moral Limits of Markets our transition from a market economy to a market society. While free market capitalism has demonstrated its ability to efficiently organize productive activity and allocate goods and services, this efficiency comes at a cost. One concern, discussed previously, is how markets can produce inequity. Inequitable distribution may be tolerable for some things (video games, Broadway shows) but not for others (insulin, cancer screening.) A more subtle, but perhaps more concerning, concern about marketization is its corrupting effect. Even if we can make a market for healthcare less unfair, it may still be undesirable.
Market theory assumes that the value of a thing is fully reflected in people’s willingness to pay for it. But it is easy to think of examples of things that have an intrinsic value that cannot be readily expressed in monetary terms. I have a hat that belonged to my grandfather. I am sure that I could find a similar hat in a vintage store, but it wouldn’t be the same hat. The hat that I have can never be replaced. It is, effectively, priceless. Indeed, there are things that are literally priceless. Sandel uses the example of the Nobel Prize. It has value exactly because it cannot be purchased; it can only be earned. His point is that if we try to commoditize something, we can reduce its intrinsic value. Once there is a market for Nobel Prizes, they cease to have any real value. (Keep in mind, he was writing in 2012, long before a US President would openly campaign to buy one. That craziness notwithstanding, Sandel’s point remains valid.)
Even if commercialization doesn’t devalue something, it can change the nature of it. Blood donation in the US is an act of altruism. If we begin to pay for it, then it becomes a commercial transaction. The motivation for doing it shifts from an intrinsic one (desire to help others) to an extrinsic one (monetary reward). And studies have shown that extrinsic motivations can crowd out intrinsic ones. If the expectation is that you get paid to donate blood, willingness to do so without pay decreases. At the same time, extrinsic motivations are generally weaker and more fickle. During economic boom times, the blood supply becomes vulnerable as fewer people need the money they can get from giving blood.
If you want to get under a clinician’s skin, ask them about RVUs (relative value units). This is a system of quantifying the “value” of a physician or other provider’s work. They are used to measure clinician productivity, and compensation is often tied to worked RVUs. The intrinsic motivation of taking care of people is supplanted by the extrinsic motivation of generating RVUs. Studies have linked RVU-based compensation with decreased physician satisfaction and burnout.
Monetary incentives may be effective in delivering a result, but not necessarily the desired one. Paying a child to read will likely lead them to read more books, but it does not necessarily lead to an increased love of reading. It may even lead to gaming the system by the child reading books below their reading level – quantity over quality. Paying a clinician to generate more RVUs will lead to more patients being seen, but not necessarily to better or more compassionate care.
Indeed, by supplanting intrinsic motivation, monetary incentives can backfire. A study in Israel found that after instituting a payment for people who picked up their children late from a day care, late pickups actually increased. Rather than being motivated by shame for inconveniencing the staff, many parents simply felt that coming late was a preference they could pay for if they wanted.
One subtle form of corruption produced by marketizing things is it can send an unintended moral signal. According to market theory, motivations are preferences, these preferences are equally valid, and they are rationally expressed in the form of a willingness to pay for them. It does not draw a moral distinction between, say, choosing to buy a TV versus a gun, or one gun versus 100. Making healthcare a market commodity, it simply becomes one among many equally morally valid options. It signals that if someone chooses to spend their money gambling in Vegas instead of purchasing health insurance, that is morally OK. Libertarians would undoubtedly agree with that; who are we to judge someone for choosing craps over coverage? Even if this did not unfairly create a societal burden (the gambler can rest easy knowing that they can’t be turned away from an ER even if they can’t afford to pay), and they really would suffer the consequences of their decision, I know for me – and I think for many of us – the idea that healthcare is no different from anything else you can obtain for money doesn’t sit quite right.
There will, of course, always be economic considerations. After all, nurses and doctors, manufacturers of drugs and medical devices, discoverers of new cures, and others all expect and deserve to be appropriately paid for their contributions. And as with education, to an extent the healthcare system needs to accommodate differences in individual needs and preferences, often most efficiently expressed in market terms. But healthcare, like education, is not a commodity. These are social goods. When people are healthy and well-educated, not only do they benefit themselves, but all of society benefits. As more and more of the healthcare system becomes subject entirely to the forces of the market, we risk unacceptable inequities in access, and corruption of the underlying values that underpin it. I don’t think it’s being overly sentimental to hope that the noble intrinsic motivations of the millions of dedicated people working in that system are not supplanted and degraded by more materialistic external ones. It’s called healthcare for a reason.
Starting With Curious 