From consumer choice to consumer welfare.

In trying to understand the SUPPORT study, it may be useful to think of contemporary bioethics reform in terms of the principles of consumer protection. The central tendency of that reform (particularly in my own field--the law) has been to employ the model of consumer choice. That model sets as its purpose to allow consumers to choose the kinds of products they prefer. It seeks to accomplish that purpose primarily by supplying consumers the information they need to make choices and by insisting that they are given what they chose. Thus, for example, merchants may be required to reveal the actual terms under which they sell goods on credit, so that customers may decide whether they wish to pay the price. And once the customer has chosen a purchase, the merchant is held to the terms originally agreed upon. In short, the consumer choice model seeks to allow customers to make successful choices by providing them with a market that works in the economist's sense, efficiently. Bioethical reform may be understood along these lines. The doctrine of informed consent is, plainly, intended to provide patients the information they need to make wise choices that express their preferences. The patient is thus to become a consumer well-enough informed to make sensible choices in the market for medical care. The patient's choices are then given more binding effect by, for example, various provisions for advance directives. The consumer choice model is hardly startling and surely makes a good deal of sense. The free-market prescription was, for instance, quite successful when it was employed during the New Deal to improve the operation of the securities market. But of course the consumer choice model rests on some consequential assumptions. It assumes, for one thing, that human preferences differ so much that it is best to let people make purchasing decisions for themselves. It assumes an engaged and energetic purchaser. Finally, it assumes that people's preferences are clear and strong enough to drive them to act on the information they receive to make choices and follow up on them. Thus the New Deal reforms of the securities markets were plausible because many of the people who trade in that market know their way around it, have ready access to the information that is provided, have commanding incentives to use it, and know how to do so. The SUPPORT study does not speak directly to all these assumptions. Nor could any single study definitively establish whether such assumptions arc true. Nevertheless, this ambitious and impressive research raises some fruitful questions about the consumer choice model as it has been applied in medicine. The SUPPORT enterprise followed that model in trying to increase the communication between doctor and patient so that both could make better decisions. But what is striking about the study is, despite a commitment of resources (and, one suspects, enthusiasm) unlikely to be even matched, much less sustained, in the dullness of daily life, the SUPPORT instantiation of the model quite failed to produce statistically significant benefits. What are we to make of this unsettling negative? To put the point simply, a strong reading of the study raises questions about the usefulness of continuing to emphasize the consumer choice model. In saying this, I am far from suggesting that efforts to implement the consumer choice model in bioethics have been wasted. I suspect that that model has helped spur changes in medical attitudes which were necessary to make doctors' behavior more tolerable to contemporary American mores. My point, rather, is that--strongly read--the SUPPORT study provokes doubts about the profit of sustaining the consumer choice model at its present preeminence. But how strongly should we read the SUPPORT data? Our answer will depend on many things. But one reason to read it strongly is that SUPPORT seems to confirm what we already know about the effects of some other bioethical reforms in the consumer choice model--that those reforms often seem to have fewer consequences than the consumer choice model seems to call for. …