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The Trouble With Doctors

Brian D. Rude 1991

Revised 2006

      Motives are always complex, and that is as true for doctors as for anyone else. Doctors have many motives that are quite understandable. They want their patients to get well. They want to be appreciated. And they want to have a good income. Unfortunately this last motive seems to dominate. The amounts doctors charge for their services is one thing, but not the only one, that elicits in me a good deal of hostility against them

      My thoughts about doctors developed slowly over the first half of my lifetime. I did not think poorly of doctors when I was young. I thought very little about them then. I have been blessed with fairly good health most of my life. But over the years I have had a number of personal experiences that lead me to my present opinions. And I have ways of thinking about these experiences that apparently others do not share. I do not wish to make this article a litany of my personal complaints. Many people have bad experiences, in many different aspects of life, that do not prove anything. However I think it is also true that some of my experiences are good ways to introduce ideas. So I will include a few personal experiences.

      In my mid twenties I had appendicitis. I probably made a bad situation worse by not going in for help more quickly. When my wife finally convinced me to go to the emergency room I was in bad shape. It was quickly determined that I had appendicitis. I had surgery and spent about two weeks in the hospital recovering. One thing that impressed me from that experience was three visits, after my surgery, from the emergency room physician. He had initially examined me, concluded I had a ruptured appendix, and called in a surgeon. Why was he involved at all after that? He was not my regular doctor. I had never seen him before. I would have no reason to want or expect him to see me again. Yet each day for three days after surgery he came to see me for a few minutes. Perhaps, I thought at first, he is just being friendly. But after I got home a few weeks later his bill came, including $51 for three post surgery hospital visits at $17 a visit. I thought that was wrong.

      My explanation at the time was that, according to customary practice, he was entitled to a little money, so he claimed it. Being involved in my case at the beginning apparently entitled him to do follow up visits, and collect accordingly, even though there was no service needed that he could provide. I certainly didn’t ask him to come, or expect him to come. His job was done, it seemed to me, as soon as he called in the surgeon. I didn’t know why he came. He just came.

      I was making pretty good money at the time as a teacher. My salary at that time, as I recall, was $7200 a year, which translates to $3.60 an hour, not too bad in 1971. So for a “visit”, a few minutes of saying “How are you doing today?”, he wanted me to pay with 4.7 hours of work. That seemed awfully high to me. Suppose he spent ten minutes each time seeing me in the hospital. For his one-sixth of an hour I must work 4.7 hours. That is a ratio of about twenty-eight to one. That just seemed wrong. I felt victimized.

      The ratio would be even higher for someone who was not making a teacher’s salary, and I was well aware of this. Just a couple of years before this time I was making $2.10 an hour as a janitor on the night shift at a hospital. A person making that rate, and plenty of people were making less, would have to work 8.09 hours to pay for the doctor to come in and ask “How are you doing today?”. Again assuming the doctor put in ten minutes of time, the ratio of doctor’s pay to patient’s pay is about fifty to one. That angered me. The fact that in this case the doctor’s visit seemed totally unnecessary aggravated the situation, of course, but even so, why should a common man have to pay a full day’s pay for a few minutes of a doctor’s time? I knew nothing other to do than to just pay the bill, but the incident was permanently stuck in my memory.

      The costs of my appendectomy set my wife and I back. I recovered from my appendicitis, of course. My wife and I had to refinance our new car to pay our bills on time, and the remainder of my wife’s savings for college were wiped out, but, as I say, my job as a teacher paid fairly well so we were okay. My hospital experience was mostly forgotten, but I think thereafter I was always conscious of relative rates of pay.

      My reaction to these costs were mostly gut level reactions, not well thought out. Gut level reactions are important at times. I am not one to minimize them. But I do tend to analyze things also.

      There are many ways one can figure the value of a service. Unfortunately many people do not realize this. People commonly seem to think that everything has a value, an absolute value that is right and proper. If you pay less you are getting a bargain. If you pay more you are being cheated. This is a primitive understanding of value, of course, but seems good enough for most people. By this mentality we learn that a doctor visit costs $17, and a day in the hospital costs $35, (in 1971) and that’s just the way it is. We accept it. Most people don’t seem to translate a price into hours of labor, and they don’t think to compare ratios of doctor’s time to their own time. They just accept that doctor and hospital bills are high. “Thank heaven for insurance” we say (though we had little insurance in 1971), and go on with our lives.

      In recent years it has become popular to compare the ratio of the pay of the CEO of a company to the pay of the lowest paid worker. Thus we may be told that the CEO of Company X earns 400 times what the lowest paid janitor makes, with the implication being that that is awful. I am sympathetic to such comparisons, and I have some thoughts on such ratios. The ratio that I am concerned with in this article is the pay of doctors compared to what we might call minimum professional pay. It seems doctors expect to earn at least five times what nurses, policemen, teachers, or social workers earn. I think this is excessive.

      The term "price gouging" comes to mind. This is not an attractive term, and not a well defined term, but it is certainly not an unfamiliar term to the public at large. As I write this the term is most often applied to oil companies, due to the painful increase in gas prices during the past year. Generally we think of price gouging as something that arises due to unusual circumstances. Consider this scenario. A hardware store always keeps a few generators in stock. One day a particularly bad storm hits town and knocks out the electricity. After a few hours, or perhaps a day, people begin to realize the power is not going to come back on immediately. Then the utility company announces that it could be as long as two weeks before power is restored. At this point a lot of people think about buying a generator to make life more comfortable during that time. However when they go to the hardware store they find the price of generators in stock, and generators that can be obtained in a day or so, have doubled or tripled what they were the day before. What should people think about such pricing, and what should they think about the merchant? Is this price gouging? Is the merchant greedy? Should such pricing be prohibited by law?

      These are not easy questions. I have thought about them off and on for years, and I still don't have answers that satisfy me. If I were the merchant I think my course of action would be clear. I would sell the generators at the regular price. But that does not mean that I'm not greedy. I just figure that in the long run the ill will generated by price gouging would outweigh the momentary gain of high prices. I expect a lot of merchants would feel this way. And as a potential buyer of a generator in such a situation I would have a lot of ill will toward the merchant who charges two or three times the usual price. But as a philosophical question I don't know whether such pricing should be condemned or not. I do believe in a free market. Changing circumstances causes changes in value.

      The connection with doctors is this. When I go to a doctor I always feel he charges two or three times the amount that would seem reasonable to me. The "price gouging" that occurs every once in a while due to exceptional circumstances, such as the storm scenario I described, is a constant everyday thing for doctors. They always charge that way, everyday. I'm not asking doctors, or anyone else, to take a vow of poverty. Doctors ought to be well paid. But it always seems to me that they could charge half or less of what they actually charge and still easily qualify as "well paid". This is an arguable point of course, and what constitutes being "well paid" is a subjective judgment. But no one argues that they don't have high incomes. I have personally known very few doctors. As I have mentioned I have been blessed with good health so I have had little contact with them. I do not wish to make them out as scoundrels. But I do very much wish them ill in some ways, especially in the pocketbook.

      I would argue that we need some philosophic or analytic basis for judging such things as value and reasonable charges. I am not one who thinks that wage and price controls are beneficial, or can be made to work. And I am not an egalitarian who thinks everyone should be equal, or at least be paid equally. I believe in the free market, and I believe in the idea of a meritocracy, keeping in mind that such terms are wide open to different meanings and interpretations.

      There have been attempts in the past by state legislatures to pass some form of “equal pay for equal work” laws, though I’m not sure if any of these attempts ever got past the talking stage. The goal of these proposed laws, I believe, was primarily to benefit women. The idea, as I understand it, would be to codify as much as possible the factors that would justify higher compensations for some jobs over others, and to put in place some legal mechanism for preventing at least the more egregious violations of these ideals. By this line of thought a job that requires high abilities or intelligence should be paid more, and a job that requires more years of preparation should be paid more, and so on. I share these general considerations of why some jobs should pay more than others, but I have no sympathy for trying to put these ideas into law. I think these ideas do deserve consideration in any society. They are ideas that people intuitively accept, and intuitively argue from. Thus it can be argued that doctors have high abilities and have invested heavily in their training, and on that basis deserve high incomes. I accept this argument to quite an extent. I will call it the meritocracy argument.

      Then there is the idea of the free market. Instead of asking how much people “deserve” for the jobs they do, which must necessarily be a subjective judgment, we may simply observe how much other people are willing to pay. We observe what actually happens, instead of what we might think should happen. In the free market a popular entertainer may make millions even though knowledgeable people think his talents are mediocre. By the free market argument that entertainer is entitled to whatever people are willing to pay. Similarly we may observe a particular cashier in a store seems very knowledgeable and competent, yet makes a very low wage. By the free market argument this is okay since no one forces that person to take that job. The pay is simply what the management of the store finds they must offer to get the help they need.

      The free market argument and the meritocracy argument often produce similar results. Indeed I think it can be argued that a free market automatically produces a meritocracy. In a free market people may judge the merits of others and pay according to the dictates of their subjective judgments. Some people do much better in a free market than others. The meritocracy argument justifies this inequality of outcome in the public mind. People who think at all about such things conclude that, in general at least, people who make more tend to produce more, in one way or the other. So a free market and a meritocracy occur together naturally. When a government tries to pass an “equal pay for equal work” law they are trying to enforce the meritocracy argument with the power of law, and judgments of merit must be made, codified, and agreed to on a collective basis. This is very difficult to accomplish to the satisfaction of all involved.

      Both of these arguments, the meritocracy and the free market, have been used to justify the high incomes of doctors. My position is that society has been much too passive in accepting the doctors’ views. Doctor’s don’t have that much merit, and the market is not entirely free.

      I am not convinced that a medical degree is all that high class. My thinking on this was very much shaped by one acquaintance. When I was studying physics in the 1980’s I had a friend who was trying to get into medical school. He remained a physics major for three years and then was accepted into a medical school somewhere, at which time I lost track of him. As I understand it he would spend four years in medical school and then get an M.D. degree. This, in my friends case, is after studying physics for three years. Physics is not medicine. It is not even very close. If he had switched from physics to chemistry he would probably spend about three years getting a bachelors degree in chemistry, or its equivalent, and only then could begin doing graduate work, which would lead to a doctorate in chemistry after at least another four years.

      A doctorate in a solid academic subject usually takes at least three or four years after a bachelors degree in that subject, and often more. Apparently that is not the case in medicine. If a pre-medicine curriculum is not a prerequisite to medical school then how can it be argued that a MD degree is really on the doctorate level? It seems to me that a doctorate in medicine must be about equal to a masters degree in physics or some other solid academic subject. My friend was very smart and competent. I have no doubt he will be a successful doctor. But I no longer think of a medical doctorate as the equivalent of a doctorate in one of the hard sciences. Indeed I wonder if my friend became an MD sooner than he would have been able to get a masters in physics.

      Doctors are not scientists. I didn’t realize this until the last few years, and to my mind it enters into the meritocracy argument. I don't know whether doctors would claim to be scientists or not. Perhaps it's one of those things they would not claim, but are glad to let the public accept. Doctors have the latitude to use judgment in many cases, but apparently they are mostly technicians. They are practitioners, not investigators. They apply knowledge and techniques that have been proven. To do anything more, or less, puts them in professional jeopardy. It’s certainly true than some scientists are M.D.’s, but I think the average M.D. is no more a scientist than the average auto mechanic is an engineer. Indeed it makes sense that doctors are practitioners, not scientists. When people have a medical need they want their doctor to be a highly competent practitioner, not a scientist, for if their doctor is a scientist then the patient is a laboratory rat. So to say they are "highly educated" is true in one sense, but it seems to me they are not highly educated in comparison to someone with a doctorate in a hard science.

      Of course getting the medical degree is not the sum total of becoming a doctor. This gets into what I think is probably the least appealing thing about doctors - their allegiance to what I call “macho medicine”. As part of their training, in at least some cases, they are expected to put in hundred hour work weeks. On the face of it this is abuse of the public. It compromises the patients’ welfare. Then doctors have the nerve to express the attitude, “I have suffered to become a doctor. Society owes me. I can charge anything I want.” This is a manifestation of the principle of “transmission of power through submission.” We are most commonly exposed to this by being in the military, where harassment of recruits is traditional. It is also very much in evidence in the initiation rites, usually by ordeal of one sort or another, found in primitive societies. The “hazing” found in some fraternities is another example. By submitting to a group, an individual finds acceptance from the group, even support. Members of street gangs argue that they join gangs for protection from other gangs. Indeed it can be argued that there is something innate in human nature that makes us want to suffer at the hands of the group that we want to join, and thereby deserve benefits from that group. But I would argue that it is a primitive and barbaric principle, no more suitable to medical training than to the training of plumbers, teachers, or truck drivers. Doctors trying to justify their high charges with the claim that they have suffered to become a doctor will get only scorn from me. It may be true that they have suffered to become doctors, but for that their profession should be ashamed, not proud. Their suffering does not add to their claim of merit. It detracts. I don’t want a doctor who has undergone an ordeal of initiation. I want a doctor who knows medicine.

      I have no doubt that doctors, in defending their high charges, would point out that they sometimes reduce their charges in hardship cases, and I have no doubt this is sometimes true. We can call this the "compassion argument". Doctors claim to have compassion, at least sometimes. But in my mind this brings very little credit to them. It is good to reduce charges when you know the patient is poor, but what makes doctors think they know this? I presume they usually do not. They don’t ask, and most people are very hesitant to ask for charity. Obviously there are some cases when a patient simply states he can’t pay the bill. The doctor might as well just write off that charge immediately. Everyone knows you can’t get blood out of a turnip. But I expect these cases are not too common.

      My perspective on this "compassion argument" comes from my experience, but not as a patient. In the 1970’s and 80’s my wife and I had some rental properties. We took it as a point of honor to be good landlords. We generally got to know most of our renters to some extent. Since I did most of the managing of the rentals, which included a substantial amount of repair and upkeep on the properties, I got to know some of them quite well. Occasionally, as might be expected, a renter might need a little extra time to get the rent to me. There are a variety of reasons this could happen of course. But on at least several occasions the renter explained that medical bills had put them in a bind.

      A single office visit will not cost a month’s rent. But it actually doesn’t take much more than a few office visits to equal a month's rent. It is very easy to get in an accident or to develop some medical problem such that the medical bills dwarf what the family has been paying for rent.

      I cannot give specifics - I didn’t know our renters that well - but what I did learn confirmed my bad opinion of doctors. They want their money. That doesn't mean they get nasty about it. They don't have to. They simply set up their practice, which includes hiring an office staff to handle billing, and let the money roll in. People generally don't complain. They do what they have to to manage their resources. They do without. They put off what bills they can. They go into debt. They refinance their existing debts, as my wife and I did after my appendectomy. Doctors, except in unusual cases, know nothing about all this.

      It can certainly be argued that many people can’t handle their money well. They live from paycheck to paycheck and don’t have the gumption to put a little aside for emergencies. That is true enough. Some of our renters were definitely low class people. But for the most part they took their obligations very seriously. They struggled to pay their rent and to pay their medical bills. They suffered real hardship when they were hard pressed to do both. Does the doctor know this? Does he care? I think it’s probably true that many doctors would care, if they knew. The compassion argument is not entirely empty. But to say that doctors routinely know which of their patients have real hardship doesn’t seem to me to be at all realistic. The renters I knew, and the people in general that I have known throughout my life, don’t ask for charity.

      Should doctors earn five times what teachers and nurses make? I don’t think so. I wouldn’t begrudge them making twice, but I think much more is bad for society in general. The argument of merit, in my opinion, is dubious. The argument of compassion is not strong and usually irrelevant. That leaves the free market argument, and that is certainly open to question.

      Medical services are not bought and sold on an entirely free market. Admittedly, a totally free market is very hard to find. We may think of cars as being bought and sold on a free market, but perhaps it could be argued that as a practical matter the market is very unfree. It is very difficult for a new car company to get started. And there must be a vast amount of legal regulations concerned with manufacturing and selling cars. However, I think it is fair to say that government does not set out to limit our choices of cars.

      Any occupational licensing is a limit on the free market. I am not saying that there should be no occupational licensing, but I would argue that we have far too much occupational licensing. In teaching, the field I am most familiar with, I would argue (and have most of my life) that certification requirements have promoted mediocrity in teaching throughout the twentieth century. We would have better schools, in my opinion, if we totally scrapped all teacher certification requirements. I also do not support licensing of barbers and beauticians, or plumbers, or interior decorators, or house painters, or of many other occupations.

      In any testing situation there is the problem of false positives and false negatives. A false positive in teaching would be a teacher who is licensed but should not be. There are a lot of such teachers. A false negative in teaching would be a person who should be licensed but is not. There are also a lot of those people. Any false positive in occupational licensing imposes a cost on society. Any false negative in occupational licensing imposes a very high cost on the individual.

      But I am not against all occupational licensing. Perhaps medicine is the field in which licensing is most needed. It is a technical field, unlike teaching, and technical knowledge and proficiency can be judged by society with a reasonable degree of accuracy. And obviously bad doctors can do a lot of harm. But if we are going to have licensing for doctors then it should be recognized that doctors are privileged by the state. This, coupled with the prescription system, makes the market for medical services a long way from a free market. This situation certainly raises the idea that therefore doctor fees should be regulated by the state. Each state has a bureaucracy for regulating the rates of some utilities. They call it the "public utilities commission", or some similar term. The argument is that since an electric company has a monopoly of electrical services in a given area the free market can not be expected to work. Therefore control of the market by the state is both justified and needed. I would argue that this same line of reasoning applies to one extent or another whenever the state gives privileged status to members of an occupation.

      But I would not argue for state control of doctor's charges. There are many problems with that. I figured out many years ago that a public commission overseeing the rates of an electric company must first of all protect the company. The commission must set rates that are profitable to the electric company. The public is not served if rates are so low that the company underserves the public or goes out of business altogether. Electric companies know most about the data pertaining to rates and profitability of their industry, and can present that data to the governing commission in ways that are much to their advantage. Therefore a public utilities commission is probably not very effective in keeping rates down. It would probably be even less effective in trying to keep doctors' rates down.

      It seems to be human nature for people to form groups, and to protect and promote those groups at the expense of other groups. This has many consequences. There are many ways that a group may be defined. And there are many ways, some good and some not so good, that one's group may be protected and promoted. Doctors are smart, and they are organized, so I suspect they are very good in promoting and protecting themselves.

      This brings to mind an article in some magazine many years ago about daily life of a policeman. It was an interesting article, but not particularly significant - just another human interest story. But this particular article stuck in my mind because of an incident related at the end of the article. The policeman described in the article made a routine traffic stop of a speeder. The circumstances were such that a ticket and fine would be the expected outcome. However the speeder turned out to be an off-duty policeman, and therefore was not given a ticket. I'm not sure if the term "professional courtesy" was used by the author of the article, but it could have been. The author did not seem to attach much importance to this situation. It was just one more typical incident that makes up the life of policemen. But it angered me. I would not hesitate to use the word "corruption". A policeman should pay a fine when caught for speeding just like you an me. Any other standard is corruption. I do not begrudge the idea that a policeman can have some discretion in handing out tickets. I have been the beneficiary of such discretion myself. But as described in the article there were no mitigating circumstances to be considered. As described in the article the speeder was not given a ticket simply because he was a policeman himself.

      Do doctors do this? Do they "protect their own" at the expense of patients? I expect they do, though I have no "smoking gun" to offer. When the emergency room physician came to see me three times after surgery he was probably just partaking of one of the little perks of the system. Of course there may be other considerations. A consideration for doctors that is always important is to not get sued. Maybe that entered into my situation some way.

      A friend related to me the other day that he is a cancer survivor, and still must see a cancer doctor periodically. However the cancer doctor would not prescribe medicine for my friend’s high blood pressure. He had to see another doctor for that, and pay accordingly. My friend perhaps does not share my low opinion of doctors, but he did express some resentment of the situation. I don't know if he computed ratios, but I did. He had to pay with a little more than a full day of work for a few minutes of the doctor's time.

      Why can't a cancer specialist prescribe for high blood pressure? He can, of course. I myself am on medicine for high blood pressure, so I know a little about it. Finding the right medicine for hypertension involves a bit of experimentation. Of course a doctor has a much greater base of knowledge than a layman to guide that experimentation, but it is still experimentation. The two doctors I have seen (two doctors because I moved) made no pretense otherwise. Why couldn't my friend’s cancer doctor prescribe a medicine or two, tell my friend to monitor the results (which my friend mentioned he does) and instruct him to see a family practitioner if that doesn't do the job? Is it lack of knowledge on the part of the cancer specialist? That seems unlikely, but if so then it bolsters my argument that a medical degree is not that high class and doctors are mainly technicians. Is it that doctors respect each other’s domains? If so, isn't that corruption, like the policeman not giving a ticket to a fellow policeman?

      I am very much an admirer of Bill Cosby and his television show. I don’t watch much TV, but over the years I have seen his show enough to be familiar with it and at least the main characters. But I wish they had not made him a doctor. The writers of the show, or Bill, or whoever, wanted to make his character successful and affluent. That’s fine, but I wish they would have made him something like a stock broker. A rich stock broker, it seems to me, gets big bucks by helping rich people get richer. A doctor, except in very unusual cases, gets rich by taking big bucks from poor people in trouble. Of course I haven’t watched the show all that much. Perhaps episodes I haven’t seen make it clear that Dr. Huxtable doesn’t follow that usual pattern.

      I am aware, of course, that my poor opinion of doctors are not universally shared, though I also know I am not unique. Many people think highly of doctors. And perhaps this is why Dr. Huxtable was made a doctor. How can we account for the very strange fact that many people think well of doctors? I’m not sure, but I expect part of the answer is that doctors know how to do public relations. I don’t have examples of doctors taking steps to “keep incomes high”, but I do know I have heard that phrase, or some phrase like it, more than once in the past. You can’t blame a group for taking care of their image and self interest, of course. Or can you?

      Doctors are sued a lot. For most of my lifetime it has been common knowledge that doctors are sued a lot, and that therefore liability insurance rates for doctors are very high. Doctors have "deep pockets", in other words. I think this is a most unfortunate situation. It's a vicious cycle. The more doctors make they more they are targeted for lawsuits, sometimes fairly and sometimes unfairly. So they get defensive, charge even more, and convince themselves that they are victims. I have no doubt that sometimes they are victims. I blame an irresponsible public for this situation to quite an extent. All my life I have been a critic of America's penchant for suing. But I certainly also blame doctors for the situation. They have set themselves up for it. Their high charges are one way they have set themselves up for it, but certainly not the only way. There is also the "doctor knows best" mentality.

      The doctor-knows-best mentality, and doctors' exploitation of it, is another thing that I don't like about doctors. I use this term to refer to what I consider an undue deference to doctors on the part of many people. This mentality, I think, is harmful to society in general, and certainly harmful to the medical profession. It is harmful to society because it promotes passivity on the part of people. It is harmful to the medical profession because it promotes their egos too much. It has been said often that power corrupts, and it is true.

      There is really no such thing as "doctor's orders". A doctor can provide services, and he can give advice. We can take that advice, or not, as we will. Obviously we should take such advice very seriously. It is based on sound medical knowledge in most cases, and we pay dearly for it. But still it is only advice. Yet many people seem to want to invest it with some magic authority. Some people, many people even, want their doctors to be authoritative. This is hard for me to understand, but I observe it. The profession promotes this in various ways. One way is their "macho medicine", as I have already discussed. They are quick to point out that they have suffered to become doctors, and imply that therefore they know best. Obviously the connection is not one of logic.

      Some doctors are arrogant jerks. This is probably a predictable result of the doctor-knows-best mentality. Apparently it is mainly older doctors who are most prone to be arrogant. Younger doctors, according to the opinion of some of my acquaintances who know about such things, are careful not to be that way. I assume the profession has learned that it is counterproductive. I have very little personal experience with arrogant doctors, but I have heard many anecdotes from acquaintances.

      What are we to make of doctor's attitudes toward illegible prescriptions? I bring this point up because it enters into the arrogance question. My wife and I raised four children so I have seen quite a few prescriptions in my life. It is not uncommon for a prescription to not have the doctor's name and phone number in print, and for many letters and some words to be illegible. There seems to be a "good old boy" mentality on the part of doctors in this regard, an attitude that "the pharmacist knows what I mean, if not he'll give me a call". As a practical matter this is usually true, but that attitude seems to me to be contemptuous of public safety. Presumably any medicine requiring a prescription has the potential of doing harm. That is the assumption underlying the whole prescription system. And in recent years we have heard reports in the news that indeed there is a substantial death toll for medical mistakes. All this, it seems to me, points to the idea that if there is one thing in the world that ought to be written absolutely flawlessly, it is a medical prescription. Instead we seem to have a tradition of "doctor's handwriting". Doctors should be ashamed of this tradition, not proud.

      What should be the response by the public at large to doctors and their peculiar relationship to money? I do not advocate that we should try to tax doctors heavily as a way to punish them. They pay comparatively high taxes just because they have high incomes. As a matter of politics and public policy I think it is counterproductive to try to "soak the rich". I do not advocate that we try to regulate what doctors can charge, as I have already discussed. I do not advocate that we sue them frivolously. That hurts everyone. What I do advocate is that we be much more critical of them. They should get a lot more flak on their greed. They should get a lot more criticism on their macho medicine.

      One might conjecture on doctors' ideals. Is there any ideal of public service in the profession? Does anyone go into the profession because they want to do good, to serve humanity? Motives are always complex. Perhaps there are some high ideals among doctors. To say that they are motivated only by money would probably be simplistic.

      I have considered the possibility that doctors are more insensitive than avaricious. I have never heard a doctor say "Money doesn't really matter to me," but then I very seldom see or talk to doctors. I hope I never hear a doctor say it. It wouldn't help my blood pressure. But I can envision doctors thinking this, being so insensitive that they take the money for granted. It has occurred to me many years ago that a certain amount of insensitivity to pain has to be simply a part of a doctors training.

      By this “insensitivity perspective” doctors are spoiled by big money they same way you and I are spoiled by indoor plumbing. We generally can take it for granted. Perhaps some doctors take their money for granted in the same way as I take electricity for granted. But, of course, there is a tremendous difference. My indoor plumbing and electricity doesn’t make anyone poor. I can be spoiled by indoor plumbing and electricity because everyone else also can be. That is not true of doctors’ money.

      And I have also considered the possibility that doctors think of themselves as doing good. They provide services that people very much need. Therefore, perhaps they think, they must be doing good. Obviously there is some truth in this perspective. But that does not mean we should think well of doctors. What about the hardware store owner who has extra generators shipped in to meet demand after a damaging storm, and then prices $500 generators at $1600? Is he doing good? Should we think well of him because a number of people are willing to pay that price?

      Answers to questions like these are not easy and obvious. I cannot give good philosophical or analytic answers. But I would think badly of the hardware store owner, and I think badly of doctors. Others may see things differently.