Supply of Medical Services

How to pay doctors: As a Merchant or a Guardian?

The book Systems of Survival (review) describes two moral structures: commerce and guardianship.  Jane Jacobs describes the ethics of Commerce as a moral syndrome equal, antagonistic, and complementary to the ethics of politics, or Guardianship. 

  • Commerce provides the economic engine and the ethical framework for trade, technological advance, and individual rights that combine to make governments worth living under.
  • Guardianship:  Government protects commerce, provides stability, administers justice, and enforces uniform standards.

The two moral systems reflect societies dilemma of how to  pay doctors.   Republicans generally think of doctors as fitting into the Commerce ethic.  They are type-A personalities whose drive leads to medical advances and an increased standard of living.  Doctors are scientific and believe in objectivity.  

Democrats believe physicians should fit more into the Guardianship role.   One could think of doctors as “professionals” who distribute advice similar to a government official.  The doctor’s role is to provide medical care to those who need it, not maximize revenue or only treat those who can pay.

The Commerce doctor should receive FFS payment; the Guardian doctor should work on a salary.  The “guardian” doctor is best for standard day-to-day care, but the “commerce” doctor is needed to advance medical knowledge and technology.  Resolving this conflict between the doctor as a commercial agent and a guardian may hold the key to improve physician payment structures.

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