I am writing in response to Carson’s post that was a reply to a comment loyal Upset Patterns reader Joe wrote, mostly in regards to the further reply by Joe and Benji regarding the inequality of service amongst rich and poor patients.

I just got back from the wonderful city of Stockholm after flying on the extremely low-fare airline Ryanair. Ryanair sucks. If the name you book your ticket with is one letter different from your passport, they make you buy a new ticket. Every bag you check costs at least ten pounds. They fly to airports embarassingly far away from the advertised city destinaton (I took a two hour bus from the airport I flew into to get to Stockholm’s city center). There are no complimentary refreshments. If you find yourself particularly parched or hungry for whatever reason, you get screwed over by insanely expensive food sold on the plane. The interior is tacky and completely plastered by advertisements. Their website is so annoying to navigate. They also play sucky music every time the plane lands and sing something along the lines of “Wow, another Ryanair flight, on time!” Oh yeah, and, they might even start charging for bathroom usage – particularly bad for this bladderly-challenged blogger. But Ryanair’s roundtrip flight cost me about a fifth of what it would have cost me to fly with an airline like British Airways or KLM.

I’ve said before that I’m not completely convinced that ending medical licensure is the best idea. But I think it is an irrelevant argument that poor people might get Wal-Mart brand care while rich people get Mayo-clinic style care. If we decided that everyone should get Ritz-Carlton quality healthcare via shutting out lower-quality doctors through licensure, poor people would inevitably be the ones hurt the most. Ryanair might suck, but it’s better than having the only option be flights filled with non-necessities. The more expensive airlines actually do call for regulation that would effectively negate Ryanir’s cheapness (see: bootleggers and baptists). If there were no Ryanair or Easyjet, everyone would have to pay 500 dollars to fly from Edinburgh to Stockholm. As bad as Ryanair might be, shouldn’t the option of an uncomfortable yet cheap flight be there? The last time I checked, they were the only airline to have actually grown in Europe during the current economic times, showing that they must be doing something right (especially for people on tighter budgets).

My objection to ending medical licensure comes not from an inevitable inequality in care but from the possibility of wreckless medical practices. As a few commenters pointed out, it is the imperfect information regarding doctors and the vast differences between medical practice and other industries that make me skeptical about treating medicine like a purely competitive market. On the other hand, people need to consider these things in regards to this topic:

  • Is the current AMA certification effective in preventing doctors from doing bad stuff?
  • Could the current AMA certification system give people a false sense of security?
  • Could a doctor’s reputation be a better method of communication about quality than arbitrary standards?
  • Does shutting lesser-qualified (in a really strict objective how-many-degrees-do-you-have sense) doctors out of the market help the poor by protecting them from malpractice more than it hurts them from higher prices?

For the first question, I’d say no. There are very incompetent doctors practicing and stricter licensure standards or malpractice rules will probably do very little to improve this. For the second, I’d say yes. When people see that a doctor is certified by the AMA, they probably assume that they are competent and good and don’t hesitate looking around for other doctors or considering performance history. For the third question, I’d say more “yes” than most people would think. Think of ebay. People’s trust in a seller is based completely on a seller’s reputation/rating. Ebay is an extreme, I know. But what about restaurants or general establishments around town? Do they stay in business because the government decides they are “worthy” of it or because repeated business tells other people that there may be something good about the product they are selling?

The fourth one is really just to exercise your brain and I don’t think it can be measured quantitatively at all, unfortunately. For those of you familiar with statistics, think of Type 1 and Type 2 errors. In theory, both are equally harmful. Certifying a doctor that shouldn’t be certified is just as harmful as not certifying one that should be. Is it possible that the current system commits the latter more than people think? I think so.

This is where I think my proposed middle ground, though perhaps not completely thought out, comes into play. The presence of medical licensure means that it is illegal for people who aren’t certified by the AMA to practice medicine. As much as you might trust me to give you some sort of exotic aroma therapy medicine or fix your back, I can’t because of legal hinderances. I think this is crap, just like I think that if someone is near death, they should be able to take whatever experimental drug they want – regardless of whether it is approved by the FDA. If anything, AMA licensure should be a sign of confidence from some entity – not necessarily government-run – that a doctor meets certain standards. The sign of confidence would be akin to a hotel being rated by some tourist’s association or ebay’s good seller ratings. But it should not be a legal requirement. Such rules are a complete infringement on the right of people to engage in voluntary exchange.

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