For every health policy action, there can be reciprocal overreaction.

A couple of years after Medicare and Medicaid were launched, Michael Crichton, as a fourth-year medical student at Harvard, was writing his first book, entitled Five Patients. It tells the stories of five people as their lives might be perceived by such a student as Crichton was at that time in a university teaching hospital. The book was published in 1970, is still available in paperback more than 30 years later, and is still compelling, the changes in medical technology notwithstanding. I was surprised to find that I was one of the physicians quoted on the frontispiece. The other quote that Crighton used was by my professor of medicine at Yale University in the 19503, Dr. Paul Beeson: Doctors and nurses are the only people who possibly can alter the conditions of patient care. My quote followed: Health, as a vast societal enterprise, is too important to be solely the concern of the providers of services. In using these two quotes, Crighton highlights two fundamental mindsets that still prevail in healthcare: one that allows for and even encourages patient participation and one that disregards entirely the patient in the healthcare decision-making process. HEALTHCARE MARKETS The opportunity to choose is fundamental in American society. We select hospitals not by virtue of residence, as we do primary and secondary schools, but rather by factors related to choice, as we do churches. The evaluation of healthcare is highly subjective, an extension of one's culture and beliefs. Moreover, the outcomes of healthcare are often not as desired by the consumer or the provider. Movement from one type of provider to another can be a safety valve for frustration on the part of the patient, so the patient needs a range of manageable choices (albeit something less than the free choice represented by all the listings of physicians in the yellow pages of the local telephone directory). Increasingly, consumer choice is also an element in employee health-benefit coverage. The two main players in market economics-households and firms-are in dynamic equilibrium. Households make demands, and firms supply those demands. Firms provide goods and services in exchange for money; households obtain money in exchange for labor and capital. In healthcare, the households may be seen as patients and the firms as physicians and hospitals. The equilibrium of supply and demand is guided in theory by the "invisible hand of the market," as asserted by Adam Smith (1776), a professor of moral philosophy at Glasgow University, Scotland, in The Wealth of Nations. This theory seems to hold true in industrial markets; in healthcare, however, our choices are more likely to be driven by values or moral sentiment than by economic rationality. Markets can be assessed in terms of the following principles of perfect competition: * a large number of suppliers and purchasers, * no single firm or entity controlling price, * free entry and exit of suppliers and purchasers, * free substitution of products and services, and * perfect information accessible to all suppliers and purchasers. Unfortunately, these principles have only limited applicability to healthcare markets. One example of the last principle is discussed in the "From Commentary to Critique" section below in the context of Morath's "stop the line" policy. PATIENTS AS CONSTITUENTS If "health as a vast societal enterprise is too important to be solely the concern of the providers of services," what role might the patient play? Not that of consumer. Late one evening during my internship at the Yale-New Haven Hospital, a surgical-ward nurse entered the office where I was catching up on patients' charts. An airline stewardess before attending nursing school, she asked, "Dr. Kissick, would you please look in on the passenger in the room at the end of the hall?" Her slip of the tongue was not entirely without basis. …