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Sunday, October 1, 2000

For-Profit Medicine and the Compassion Motive

The Profit Motive Brings Differing Goals Into Harmony

Tom Palmer is fellow in social thought at the Cato Institute and a member of the board of trustees of the Foundation for Economic Education.

For-profit medicine must be a terrible and immoral thing. After all, I hear it attacked as such all the time. Indeed, as I write this I’m listening to a bitter attack on private hospitals over the Canadian Broadcasting Corporation. When doctors, nurses, and hospital administrators care only about their income, compassion is replaced by cold-hearted selfishness, many people say. But I just got a new view of the issue when I found myself having to visit two hospitals—one for-profit, the other nonprofit—for relief from a painful and crippling condition.

I recently suffered from a ruptured disk in my spine that caused kinds of pain that I had never imagined possible. I visited a specialist at a local for-profit hospital, and he arranged for me to get an MRI (magnetic resonance imaging) scan within an hour at a nearby for-profit radiology clinic. Then he arranged for me to have an epidural injection to reduce the inflammation of the nerves coming into the spinal column, which were the source of the pains. I was in such agony that I could barely move at all. The for-profit pain clinic at the for-profit hospital I visited was staffed by doctors and nurses who showed me extraordinary kindness and treated me with gentleness. After the nurse had made sure that I understood the procedure and that I could understand all the directions, the doctor who administered the epidural injection introduced herself, explained every step, and then proceeded with both notable professionalism and evident concern for my well-being.

Fast forward a few weeks. My condition, although still painful and debilitating, was greatly improved. My doctor recommended another epidural injection to advance me even more toward a normal state. Unfortunately, the for-profit pain clinic was booked up completely for three weeks. I didn’t want to wait that long and called some other hospitals in the area. A very well-known and highly regarded nonprofit hospital could fit me in in two days. I gladly made an appointment.

When I got to the nonprofit hospital, I spoke first with some helpful retired ladies and gentlemen who were wearing neat volunteer uniforms. They were clearly benevolent people, as one might expect in a nonprofit hospital. Then I hobbled with my cane to the pain clinic, where I signed in with the desk. A nurse came out and announced my name and after I identified myself, sat down next to me in the lobby. The interview took place while I was surrounded with strangers. Thankfully, there were no embarrassing questions. I noticed that the other nurses were actually ordering patients about in the imperative voice. One nurse told a lady who was clearly in pain to sit in another chair and after the patient said she was more comfortable where she was, the nurse pointed to the other chair and said, “No. Sit!” When that same nurse approached me, I think that my look told her that I had no intention of being treated like an enrollee in obedience school. Wordlessly, she pointed at the examination room, which I entered.

The administering doctor walked in. No introduction. No name. No hand to shake. He looked at my file, muttered to himself, and told me to sit on the bed, pull down my pants, and hoist my shirt. I told him that the procedure had been done before while I was lying on my side, and that that position was more comfortable, since sitting was quite painful. He said that he preferred it with me sitting. I responded that I preferred to lie on my side. He said that sitting allowed better access, which was at least a reason that appealed to my interests as well as his, so I acquiesced. Then, unlike the doctor in the for-profit hospital, he slammed in the needle and injected the medication with such surprising and agonizing force that it caused me to let loose a real yell, quite unlike my previous experience. Then he removed the needle, made a note in his file, and disappeared. The nurse handed me a sheet of paper and pointed the way out. I paid and left.

Profit and Compassion

That’s too small a set of experiences on the basis of which to compare for-profit and nonprofit medicine. But it may suggest something about the profit motive and its relation to compassion. It’s not that for-profit hospitals alone attract the kindly and compassionate, since the elderly volunteers in the nonprofit hospital were surely kindly and compassionate. But I can’t help thinking that the doctors and nurses who worked in a for-profit pain clinic in a for-profit hospital had some incentive to exercise their compassion at work. After all, if I need additional treatment or if I find myself asked for a recommendation, I’m going to think of the for-profit hospital. But I will neither go back to nor recommend the nonprofit hospital, and I think I know why: the doctors and nurses there had no reason to want me to. And now I also understand why the nonprofit hospital could fit me in so quickly. I doubt they had many repeat customers.

The experience does not suggest that profits are a necessary or even sufficient condition for compassion, benevolence, or courtesy. I work at a nonprofit organization, which is dependent on the continued support of a wide base of donors. If I were to fail to fulfill my fiduciary obligations to them, they would stop supporting my work. It so happens that I and my colleagues work there because we share the same concerns as the donors, so the arrangement works out harmoniously. But when the donors, the employees, and the “clients” (whether people in pain or journalists and educators in need of information and insight) don’t all share the same values or goals, as in the nonprofit hospital, the profit motive acts powerfully to bring those goals into harmony.

Profits earned in the context of well-defined and enforced legal rights (as distinguished from the profits that accrue to being a brilliant thief) may provide the foundation not of coldness, but of compassion. The search for profit requires that the doctor consider the interests of the patient by putting himself or herself into the patient’s position, to imagine the suffering of others, to have compassion. In a free-market economy, the profit motive may be but another name for the compassion motive.

  • Dr. Palmer is executive vice president for international programs at the Atlas Network and a senior fellow at the Cato Institute and director of the Institute's educational program, Cato University.