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People often forget that the medical profession's highest priority isn't the health of you, the patient. If you were to grab a medical ethics book you will firs

People often forget that the medical profession's highest priority isn't the health of you, the patient. If you were to grab a medical ethics book you will first be told that the well being of the population as a whole surpasses any individuals rights. Let's assume a hypothetical where doctors are ranked, let's also assume that insurance will pay for all doctors. Naturally demand for these physicians or surgeons will rise dramatically. If we take Ontario (Canada) as a case, we can see a situation where there is not a free market and physicians can't start charging more. What happens? Well wait times become significantly longer and people start waiting longer to see the best physician possible rather than having a more immediate operation with a lower ranked physician. There is, of course, increased risk the longer you wait for an operation even as simple as a hernia. But patients often don't understand that and can't make logical choices without being 'forced', for lack of a better word, and told they must do it soon with surgeon X. In this case overall population health decreases, complications, morbidity and mortality rise from delays. You also run the risk of complex patients being unable to be operated on by the best because they are too busy doing an operation on a cut and dry case. This is the case in Ontario (largely anecdotal evidence, albeit from a very large pool) where people flock to Toronto on the perceived notion that surgeons affiliated with the most academically prestigious medical school are better than those in a community centre. It is important to ask whether the lower ranked surgeons should or should not be able, and allowed, to perform the operations, if they are unqualified they shouldn't be allows to practice. The idea of rankings to improve patient care really rests on the notion that the lower ranked surgeons have an effectively higher risk rate (note that I did not say statistically significant). Saying that complications go down from 2% to 1% with higher surgeons while significant is not effectively a difference that should affect choice. I don't know the precise numbers but this is something that must also be considered before making any judgements. While I have no vested interest, and no opinion on the matter, it is important to think why the system is the way it is rather than blindly changing things in the name of progress. This system would allow physicians to charge more in the US (due to more demand, which has it's own slew of ethical considerations) and the medical establishment is greedy to say the least. If the top surgeons could make more money with little to no harm they would.

apsec112 13y ago
Rationing with waiting lists is dumb, always has been and always will be. The smart ways to ration are by money (better surgeons charge more), or by QALY (better surgeons do more important operations on sicker people). And even with single-payer, there's no reason you can't pay better surgeons more. It's true that not everyone can have a top surgeon. But for serious surgery, the "complication" is frequently death. It's extremely silly to tell people that 1% chance of death vs. a 2% chance of death "shouldn't affect their choice". I don't know about you, but I don't want to die, even as I accept that small chances of death are sometimes unavoidable. Regarding medical ethics, obviously in the abstract we should prefer saving ten lives to one life. But in practice, it's often better to have a rule like "don't kill people" than "kill people when it serves the common good". "Don't kill people" is very easy to understand, and very easy to enforce. The "common good" is abstract and fuzzy, and can be used to justify anything from fighting malaria in Africa to Stalin's Holodomor ("can't make an omelet without breaking some eggs").
- haldujai 13y ago
  Sorry but you're incorrect. Your assumption of the complication being death is exaggerated, the surgery in question here is not that serious. Even if it were death someone would have to model the adverse effects of the increased waiting list. People waiting might result in an increase in mortality surpassing the doubled risk from surgeon error. How do you quantify which surgeons are better? I'm not an expert but surely this study's methodology is not without it's own assumptions. Things like complication rate vary wildly with patient population and other factors. This isn't a telemarketing job where you quantify easily. Similarly how can you quantify who the best programmer is? What is the economic cost of quantifying who the best surgeon is? How expensive is it to apply this study to every surgery? We must ensure that the rankings system is valid before applying it to prevent perverse incentives such as only taking low risk cases. You don't want a USNews Week type system like you have for universities which has obvious flaws and biases. You say waiting lists are dumb, but why? Are you 'killing people' by letting an inferior surgeon operate? Why is 'don't kill people' easy to understand and enforce? By not killing one to save ten are you not killing ten people? You're seeing this as black and white. This is not the case. Whether it is better to save one or ten I am not the person to judge, but you are oversimplifying this drastically. The ethical question here is NOT sentencing someone to death like killing someone to harvest organs. It's more similar to doing nothing to save someone most likely to die in order to save ten, like how they do military triage. Life is 'abstract and fuzzy'. This isn't an engineering challenge, as you say there are several things to consider. Stalin ignored the human aspect, is this right or wrong? How can you blindly answer this without supporting your conclusion. What seems humane isn't always the right answer to things. By your same argument are layoffs ever justified despite it being for the common good for the company and the remaining employees?

apsec112 13y ago

Rationing with waiting lists is dumb, always has been and always will be. The smart ways to ration are by money (better surgeons charge more), or by QALY (better surgeons do more important operations on sicker people). And even with single-payer, there's no reason you can't pay better surgeons more. It's true that not everyone can have a top surgeon. But for serious surgery, the "complication" is frequently death. It's extremely silly to tell people that 1% chance of death vs. a 2% chance of death "shouldn't affect their choice". I don't know about you, but I don't want to die, even as I accept that small chances of death are sometimes unavoidable. Regarding medical ethics, obviously in the abstract we should prefer saving ten lives to one life. But in practice, it's often better to have a rule like "don't kill people" than "kill people when it serves the common good". "Don't kill people" is very easy to understand, and very easy to enforce. The "common good" is abstract and fuzzy, and can be used to justify anything from fighting malaria in Africa to Stalin's Holodomor ("can't make an omelet without breaking some eggs").

haldujai 13y ago
Sorry but you're incorrect. Your assumption of the complication being death is exaggerated, the surgery in question here is not that serious. Even if it were death someone would have to model the adverse effects of the increased waiting list. People waiting might result in an increase in mortality surpassing the doubled risk from surgeon error. How do you quantify which surgeons are better? I'm not an expert but surely this study's methodology is not without it's own assumptions. Things like complication rate vary wildly with patient population and other factors. This isn't a telemarketing job where you quantify easily. Similarly how can you quantify who the best programmer is? What is the economic cost of quantifying who the best surgeon is? How expensive is it to apply this study to every surgery? We must ensure that the rankings system is valid before applying it to prevent perverse incentives such as only taking low risk cases. You don't want a USNews Week type system like you have for universities which has obvious flaws and biases. You say waiting lists are dumb, but why? Are you 'killing people' by letting an inferior surgeon operate? Why is 'don't kill people' easy to understand and enforce? By not killing one to save ten are you not killing ten people? You're seeing this as black and white. This is not the case. Whether it is better to save one or ten I am not the person to judge, but you are oversimplifying this drastically. The ethical question here is NOT sentencing someone to death like killing someone to harvest organs. It's more similar to doing nothing to save someone most likely to die in order to save ten, like how they do military triage. Life is 'abstract and fuzzy'. This isn't an engineering challenge, as you say there are several things to consider. Stalin ignored the human aspect, is this right or wrong? How can you blindly answer this without supporting your conclusion. What seems humane isn't always the right answer to things. By your same argument are layoffs ever justified despite it being for the common good for the company and the remaining employees?