April 3, 2019 / 1:48 PM / 2 months ago

Breakingviews - Hadas: What a new hip taught me about economics

LONDON (Reuters Breakingviews) - A total hip replacement is an excellent opportunity to put economic theory to a medical test. As the codeine wore off after my successful operation last week, I pondered the validity of some long-standing economic theories. What follows are four lessons I learned from my three days at The Manor Hospital in Oxford, a small private facility where the UK’s National Health Service sent me for this very common surgery.

Workers place construction chains at the Karl Marx sculpture of the Marx-Engels monument in Berlin September 8, 2010. REUTERS/Tobias Schwarz

The first lesson started when my surgeon reassured me by describing the forthcoming operation as something like an assembly line. Snip and cut, insert and sew up. He had supervised the procedure so many times it was almost mechanical.

The analogy reminded me of Adam Smith’s description of the dulling effect of specialised labour on the minds of workers who are little more than particularly flexible machines. “The man whose life is spent in performing a few simple operations … naturally … becomes as stupid and ignorant as it is possible for a human creature to become.”

My surgeon was obviously anything but stupid and ignorant. Nor were any of the numerous specialised carers in the hospital, from the cleaning and catering staff to the physiotherapists and nurses. As they exercised their quasi-industrial skills, we had lively conversations about work, health and life in general.

Though the sophistication of their tasks ranged greatly, the hospital was the opposite of a dystopian and dehumanising production site. Smith, considered the founder of modern economics, did not anticipate how the specialisation of labour would allow people to develop their personalities along with their technical skills.

The second lesson was about Karl Marx. In February 1848, the intellectual father of communism claimed that “all history has been a history of class struggles” and that the modern age had reduced the struggle to a simple fight of “Bourgeoisie and Proletariat”. My NHS experience did not support that reading.

Hospitals certainly look like a prime breeding ground for class resentment. Status is clearly marked in everything from titles to uniforms. Obedience to the higher-ups is mandatory. However, there were no signs of Marxist conflict at the Manor.

For one thing, pretty much everyone working there, from the lowest-paid cleaners to the most well remunerated surgeons, could be classified as bourgeois. More important, the community of effort was more potent than any class resentment. The concept of a unified care team might sound hackneyed, but for me it was a 24-hour-a-day reality.

Manor Hospital is not a socialist utopia. I am sure many workers at the hospital feel, probably justly, that the system treats them unfairly. Still, the brutal Marxian vision of inevitable and bitter social conflicts simply did not apply.

Third, Max Weber and his followers were completely right about the bureaucratic nature of the modern economy. The German sociologist did not discuss medicine, but this industry fits his century-old description of “habitual virtuosity in the mastery of single yet methodically integrated functions”.

From the arrow marking the correct leg (“we never say ‘right’”) to the countless checklists and detailed records, innumerable tasks and responsibilities were assigned and completed according to precise rules. Such box-ticking may sound grimly impersonal, as if my hip were no more than a package to be processed in an Amazon warehouse. It certainly did not feel that way.

On the contrary, the confidence that everyone knew and basically did exactly what had to be done seemed to create a friendly psychological space. The staff could build supportive personal relationships around and on top of their professional responsibilities.

Finally, I learned that the fanatical economists who think markets are the cure for all economic problems had never considered medical bureaucracy. Markets are too crude for this complex ballet of distant preparation and well-executed and well-coordinated steps.

The main problem is that markets rely on prices. But even if medical pricing were consistent (not true of the American system), these numbers are almost irrelevant to the hard parts of arranging care. Prices can provide no guidance for making choices about medical investments and education, or about the allocation of resources to different conditions.

Further, market signals do not create shared effort. Also, markets can only ration healthcare by the ability to pay, a method which seems out of line with democratic values.

I hope the opioids have not addled my thinking. I certainly understand that planned systems often get things wrong. Indeed, I was a beneficiary of a mistaken overestimate of the need for hip replacements in my area. I did not have to wait for the operation, and the staff were relatively relaxed.

Still, the basic lessons hold true in any modern hospital in any developed economy. The labour of acute medical care can be and often is more stimulating than stultifying. It is more communal than class-ridden. It is bureaucratic without necessarily being dehumanising. And market thinking is not suitable for either the wonders or the woes of modern medical care.


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