Thursday, 24 December 2009

Medical licensing

Following on from my thoughts about what a libertarian driving model might look like, I then thought about other kinds of licensing, specifically one of the issues that causes me the most confusion: medical licensing, or the licensing of both medicines and medical practitioners.

Although I am adamantly in favour of a free market in medical practice and in providing nostrums it is on the basis that the medical practitioners, purveyors of medicines and manufacturers of medicines are somehow competent to do so. While I am quite happy for Boateng and Demetriou to open their competition to Marks and Spencer from their spare bedroom, I'm considerably more ambivalent about the idea of going to Boateng and Demetriou Proctology Practitioners or sending my daughter to Paul Gadd, Pediatrician.

While doctors are fairly regularly "struck off" for various shenanigans and pharma companies occasionally display questionable ethics in their research and we have the odd Shipman-alike, by and large, I think most people are reasonably comfortable when they go to a doctor, he or she is not a complete charlatan. They may be fucking useless (and all the doctors I've dealt with in the UK seem to need detailed lessons in telling their anus from their antecubital fossa) and ... OK, so the UK's doctors may not be the best example for this. But I've been in countries where I did trust the doctors pretty much implicitly or did trust that if I tried a couple, I'd eventually find someone that I did trust among the list of regulated doctors.

But if there was no regulation, we'd have to do a lot more research into our doctors. So, gentle reader: does the convenience of medical regulation outweigh the cost of the barrier to entry? Is there a way to square this circle?

Is it possible that a voluntary submission to regulation to reassure the average punter while still allowing anyone who wants to, to practice, dispense or produce medicine with a greater warning of caveat emptor to the consumer?


Oldrightie said...

My immediate response is "If it's not broke don't fix it."

Umbongo said...

Why regulation? If we had competing medical associations which certificated their members we'd soon learn which association's qualifications were worth something and which were useless. For instance, anybody can call themselves an "accountant" in the UK. However if you want someone who is seriously qualified, only members of a couple of the more venerable institutes are worthwhile considering. Mind you, a certificate from even the most venerable of institutes should not be taken as a cast-iron guarantee of competence or good judgement. After all, this creep claims membership of the senior body in English accountancy, the Institute of Chartered Accountants in England & Wales.

The Great Simpleton said...

What you are talking about is the State not providing the licencing. What is likely to happen in practice is that the BMJ would get some competition. Doctors would want to be accredited to something if only to help with their own brand.

People would soon figure out which of these associations was worthy and choose doctors based accordingly. Furthermore, even if wasn't compulsory, doctors would soon start insuring themselves as a protection.The cost of that insurance would be a good indicator of how competent they were.

Finally, what about the poor and those who can't lok after themselves, they will lose out? Would come the claim from lefties. They would assert that the poor would be left with the worst doctors. In a free market and a society based on libertarian principles we would see the emergence of charities to look after the poor and ensure that they don't get ripped off, a bit like we had before the NHS.

Anonymous said...

Dear Mr Clown

Competing associations would evolve, some better than others in both entry requirements and subsequent training and discipline. They would break away from existing institutions like the BMA.

Personal recommendation would sort the good from the bad - just as they do for state schools (but the state keeps bad schools open, so parents have to buy a premium home in the good school's catchment). Competing professional bodies would do something when the public complained about their members; state sponsored monoplies don't.

Medicines would work the same way as any other consumable. Food producers do not poison their customers because of the Food Standards Agency. They don't poison their customers, despite the FSA.

Without state interference, similar structures to state regulation would evolve minus the threat of state sponsored beatings up of transgressors(and also minus the state defending the indefensible). People could sue for damage due to negligence or malpractice.

As for the poor, who would they be? In a libertarian society they would tend to be voluntarily poor - like me. Help or ignore them as you wish.

The sick and disabled? Voluntary charity is far better quality than state sponsored compulsory charity executed with a big stick.

Tim Worstall said...

This is what Milton Friedman did his Doctoral dissertation on. So don't hold your breath for a solution. But why not try looking that dissertation up? Must be on hte web somewhere.

Falco said...

In Iceland, (I'm not sure if this is still the case but it certainly was until recently), anyone is allowed to practice medicine, no qualification required. However, if you never qualified as a doctor then you have to put "Scottulaejnir" on your sign which roughly translates as charlatan or quack.

Tomrat said...


One theory about other means for, say, the police to evolve (say, it didn't come from landed gentry/authoritarian hellhole to enlightenment and everywhere in between) is that competing agencies vying for business would eventually set up a singular entity to arbitrate criminal matters in a way we could all more or less agree to (in the classical liberal sense).

Likewise you need to be clear what you are asking here; are we saying we want competing medical registries or the means to bestow the title "doctor" to trained professionals?where would it stop if there was no barrier to entry? To clarify if there were no agency responsible for granting titles I would immeadiately call myself Sir Professor Tomrat, Knight Garter of The Mudpile of Leeds and allround good guy (currently it is one of the queens jobs to grant royal assent to universities enabling to grant titles like doctor or professor).

If you want to know about medical drug licencing BTW reply - I'll post on it as it is an area I am very au fait with.

Jock Coats said...

I think it is instructive to look at the history of medical accreditation in the US. There, it was the upper-middle class white male universities who ran the established medical schools who called for a centralised accreditation regime so they could exclude the colleges that had sprung up to teach women and minority communities medicine and whose graduates were the ones most likely to do "bulk deals" with mutual and friendly societies to provide low cost medical care for millions of the working poor.

There is a huge economic rent in medicine and all other professions that have such centralised accreditation schemes.

Why should someone have to go through such broad-based medical training, for example, if they are not going to use most of it. You could find bodies accrediting people to perform particular procedures (some of which need not be terribly complicated and need not require someone to be paid £75k or whatever the "jobbing" GP gets these days to perform) - in a sense in the way the "Royal Colleges" do today but for much more minor treatments.

Since someone has raised the rather unedifying figure of Richard Murphy, I note that he believes this sort of "choice" is one he does not believe an average person capable of exercising and therefore that government needs to do it for us. That of course is a specious argument - in an open market one might for example expect dedicated advisors to spring up, just as those who advise us on where to put our life's savings.

Yet look also at the fairly frequent and not-insignificant differences within the profession and the medical research community about different things - there is so much of which we are uncertain and open to learned debate on about the human body - yet under a single accreditation system there is little room for practical differences in styles of treatment. The single accredited regime of continuing professional development imposes yet more standardisation. Whilst this may be a precautionary approach, it undoubtedly actually slows down medical advance, probably to the disadvantage of many sufferers for which the innate conservatism of "one size fits all" is meant to "protect".

There are lots of possible ways of accrediting medical personnel, advising which ones are best for someone and so on that one could envisage in an open market, and to me the current system is one of the biggest causes of inflated costs (as it was intended to be by the likes of those US white upper-middle class academies who saw their incomes draining away if these black and women colleges were allowed to do wholesale deals for their services and so on) and arrested development in health care.

Furthermore, there is actually not a huge incentive for the likes of the British system to keep a really close eye on their accredited practitioners. Sure, malpractice awards have been rising, but because so many people view it as "our NHS" and claims against them not reallty the "done thing" for many we accept the apology of state regulators and promises to try harder in future, rather than, say, insurers who would be fully financially liable for people they accredited making damned sure those they did insure were really worth insuring and wouldn't cost them too much money in claims.

And finally, really, we also need to remember that so much of what our system exists to treat are the illnesses of poverty (especially in old age) which, in a freer market, and an economic environment where more people would get to keep more of what they make (which would be more anyway) and make proper provision for themselves and their old age would be much diminished and capacity in the medical system/market would shift further away from treating such avoidable ailments to working harder on the more intractable killers.

Mark Wadsworth said...

"does the convenience of medical regulation outweigh the cost of the barrier to entry?"

Hang about here. Barriers to entry are mainly a problem because the incumbents create an artificial shortage of (whatever), in this case doctors, who can thus charge higher prices.

As long as the barrier to entry merely tests competence without preventing competent people from practising, then it's not really an issue, is it?

A competence test which excludes e.g. me would be a Good Thing, as testing me is probably cheaper than setting me loose and no doubt killing somebody.