Who's the Keeper of the Commons?
Submitted by Dr. JG Kaplan on Fri, 2009-10-30 08:23
Garrett Hardin, professor of biology, University of California, Santa Barbara’s essay “The Tragedy of the Commons”1 tells us about herders who, not out of greed, but out of practical necessity graze more cattle than the finite, common land can support, ruining it for everyone.
This exploitation is analogous to what happens when incentives are not aligned in a health care system (or 'non-system,' as it were) with payers, practitioners and patients doing what they feel they must without accountability for cost-effectiveness or cost-utility.
1. Hardin G. "“The Tragedy of the Commons”." Science 1968;162:1243-1248. [Free Full Text]
Although Professor Hardin was speaking to issues of our fragile planet, his message is apropos of the current healthcare reform discussion: the business of medicine is medical business. It is not insurance business; not specialist before primary care; not mindless and not cookbook medicine.
Our mutual responsibility in
Our mutual responsibility in health care....
"In his classic 1968 essay "The Tragedy of the Commons," Hardin presented the dilemma of situations for which there is no technical solution.7 Hardin used the example of cattle overpopulating a pasture, which benefits the individual herdsman who reaps the benefit of the sale of an additional cow but punishes all herdsmen by a small amount because of overgrazing. He argues that to resolve such issues, the only approach is to change human values or ideas of morality. In 21st-century medicine, it is naive to appeal to the conscience of a physician or patient to make such difficult decisions. Physicians are much more comfortable deploying resources to promote the health of individual patients than to steward resources so they can be distributed for the greatest good. The only solution, argues Hardin, is mutual (agreed upon by the majority of those affected) coercion,* which in health care includes rationing."
Miracles, Choices, and JusticeTragedy of the Future Commons
David B. Reuben, MD
JAMA. 2010;304(4):467-468. doi:10.1001/jama.2010.1048
* Hardin G. The tragedy of the commons. Science. 1968;162:1243-1248.
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