Economism and the Commercialization of Health Care Howard Brody

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ay-for-performance (P4P) represents an effort to improve the quality of health care by paying physicians more if they meet specified target measures. There are both empirical and theoretical reasons to be deeply suspicious of P4P schemes applied at the level of the individual physician or health provider. Most P4P programs were implemented before there were any good data to demonstrate that they achieved the desired results. Once such schemes were in use, the available data are far from reassuring.1 Common findings are that providers may do more of the specific procedure that is being measured, but in the process may neglect to do other things that equally affect quality of care. Payers often find that the cost of implementing a P4P program far exceeds the value of the very modest resulting improvements; and payments may unfairly benefit providers who are already meeting quality targets while disadvantaging those who make the most strenuous efforts to improve. There are also recurring signs of providers gaming the system by (for example) refusing to take care of the sickest and most difficult patients. Even before P4P was used widely, Berwick summarized the social-psychological reasons to fear that its implementation would be deleterious to medical practice.2 Replacing voluntary actions done for the good of others with paid transactions is likely to have ripple effects beyond the narrow action which can be detrimental to the entire system. A basic ethical concern with P4P that has gone almost totally unacknowledged by its champions is the fundamental disconnect between professionalism (as an ethical ideal in medicine) and P4P.3 Professionalism represents a commitment to do what is best for the patient regardless of how much the provider is paid. P4P assumes that providers will do what’s best for the patient only to the extent that they are explicitly paid to do so. It is quite possible that this contradiction is apparent rather than real, and that a properly nuanced P4P plan, combined with a sophisticated conceptualization of what professionalism requires, could reconcile the apparently conflicting features in a way that works to the patients’ benefit. But to arrive at such a happy conclusion, it would seem that the problem must be squarely addressed; and few P4P proposals even admit that the problem exists. Despite these sound reasons to adopt at the very least a go-slow approach to P4P implementation, the U.S. Affordable Care Act of 2010 is replete with provisions expanding P4P.4 Most policymakers and poliHoward Brody, M.D., Ph.D., is the Director of the Institute for the Medical Humanities at the University of Texas Medical Branch, Galveston.

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ticians today appear simply to assume that of all the ways one might reimburse physicians, only P4P makes any sense. My claim in this paper is that this uncritical love affair with P4P, in the face of both reason and evidence, is merely one example of the larger relationship between the forces of commercialization generally and the practice of medicine and health care. That is, it would be very difficult to explain what is happening in health care if the larger society did not demonstrate certain attitudes and assumptions regarding commercialization. These attitudes and assumptions form a belief system that today goes by many different names, but which I prefer to call economism.

Terminology Economism is a term that has achieved some currency among scholars of the ethics of international develop-

ideology at all, but merely as the only possible way for reasonable people to see the real world. It no more needs a name than the proverbial fish need a word for water. Moreover, it is typical of the critics, not only to use one term or another to describe the ideology, but also to fail to cross-reference thinkers who use different terms — as if they are not even aware that others are contributing to the same body of criticism. This seems to reflect the marginal status of the critics of economism in today’s society. In what follows I will for simplicity use the term economism in place of any alternative label, regardless of what term the cited author uses.

What Is Economism? Gasper described economism as having six central characteristics, which could be summarized as saying that “the economy” is the most important component of a society, that people are best understood funda-

My claim in this paper is that this uncritical love affair with P4P, in the face of both reason and evidence, is merely one example of the larger relationship between the forces of commercialization generally and the practice of medicine and health care. That is, it would be very difficult to explain what is happening in health care if the larger society did not demonstrate certain attitudes and assumptions regarding commercialization. These attitudes and assumptions form a belief system that today goes by many different names, but which I prefer to call economism. ment.5 I prefer this term because the distinction between “economics” and “economism” to some degree parallels the distinction between “science” and “scientism.”6 However, the term neoliberalism is in more widespread use among historians and sociologists. “Neoliberalism” can claim to be historically more correct, since it was briefly adopted around 1950 by the Mont Pellerin Society, generally credited as the modern source of this ideology, as their own preferred label for their ideas.7 One of the interesting features of the growing scholarship on economism/neoliberalism is the plethora of terms for what appears to be the same idea — market fundamentalism, market triumphalism, market populism, and others.8 Rather than a minor footnote, I take this state of terminological confusion to be indicative of economism’s success as a central ideology of American society since the late 1970s. These terms are virtually never invoked by defenders of the ideology, only by its relatively small band of critics. The defenders need no name for the ideology because they perceive it as not an

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mentally as economic beings (homo economicus), that economic calculation is the best way to both understand and manage all aspects of human life, and that the economy must be managed according to its own internal laws by technical experts, without interference from politicians or moralists.9 Mirowski argues that economism is more complex than this and offers a list of thirteen key points. 10 The key difference between the two lists is that Gasper attempts at least initially to take economism at face value. Mirowski believes that economism cannot be understood unless we grasp its double-faced nature. There is, in effect, one economism for the inner circle and quite a different economism to be promulgated as the public face of the movement. For example, the public face proclaims economism as pro-democratic and as trying everywhere to shrink the power of big government. The inner circle can admit privately that democracy poses a threat to the technical experts who really understand the economy, and that a strong (so long as malleable)

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government is needed to buttress and protect corporate powers and privileges. Somers offers a way to better understand Mirowski’s characterization of economism by distinguishing among three different ways economism can operate: as a descriptive narrative, as a well-funded social movement supporting and promoting that narrative, and as a set of techniques that proposes specific policy solutions for specific problems.11 Currently in America one can find all these dimensions of economism, and it is not uncommon to note contradictions among the accounts given by economism’s advocates when they assume different operational roles. For example, a central pillar of economism as ideological narrative is the absolute need to shrink the size and power of government; yet when advocates of economism design practical policy, it often takes the form of expanding governmental scope, so long as that power is used to bolster the influence of large corporations. Sandel offers a helpful summary statement by distinguishing between having a market economy and being a market society.12 If we have a market economy, we agree that a certain portion of social activity is best managed through the general mechanism of market exchanges. Since this is only a part and not the whole of social activity, the economy needs to be managed in such a way that important social values are protected and general social goals are served, and this requires some degree of regulation. We can then agree that within the bounds set for it, the market is an excellent means to achieve many important goals, and can be allowed more or less to manage itself on its own terms. Adam Smith’s famous metaphor of the “invisible hand” describes how good a job the market often does of this self-regulation, but again, only so long as it remains within its appointed bounds and social framework (as Smith himself clearly understood). By contrast, being a market society describes the ideology of economism. Sandel summarizes, “The difference is this: A market economy is a tool — a valuable and effective tool — for organizing productive activity. A market society is a way of life in which market values seep into every aspect of human endeavor. It’s a place where social relations are made over in the image of the market.”13 The economy is no longer a part of society; it is the society. The market is not expected to cohere with important social values; the market defines and dictates those values. The market is not expected to stay within certain bounds; the market has no bounds and is assumed to be flawlessly self-regulating. (“Self-regulating” becomes tautological, since whatever the “free” market ends up doing, no

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matter how destructive to the welfare of the majority of the population, is by definition a “good” outcome.) Sandel argues that turning a market economy into a market society breeds two grave problems, inequality and corruption. When all basic social goods are redefined as market commodities, we guarantee that serious inequalities will arise as the rich have much greater access to goods like health care and education than do the poor. A more subtle problem is corruption as the very meaning of social goods changes when we start to think about them as market transactions. Consider for example what it means to think about marriage as an investment, and to be ready to divorce as soon as it seems that return on investment has fallen below a pre-set threshold. The same holds true about important human relationships in health care.

Economism as Quasi-Religion Economism has complex historical roots reaching back well into the nineteenth century and connecting with intellectual movements such as social Darwinism.14 To understand the form that economism takes today in the U.S., it helps to trace some of these roots back to religious doctrine. I have argued elsewhere that economism is historically tied to Calvinist-Puritan thought in early eighteenth-century America, when this thought was transforming into what Weber later termed the “Protestant ethic.”15 It is also connected to the form that Evangelicalism took in England in the first half of the nineteenth century.16 From its evangelical roots, today’s economism inherited a general attitude that social policies that assist the poor are bad. Evangelicalism in England in the first half of the nineteenth century preached that all of us were miserable sinners, but that each could be saved through faith in Jesus (but not through good works). Poverty on earth was divinely designed to prick the consciences of the poor (at least the “deserving” poor, as the distinction between deserving and undeserving poor became prominent at this time). With their consciences suitably pricked, the poor might find their way to faith and thus have their souls eternally saved. If any humans, however, were so misguided as to try to ease the material conditions of poverty, the loss would be the immortal souls of the poor. Earthly comfort, it was feared, would lead to loss of faith and hence eternal damnation.17 One manifestation of this history is the popularity among economism-inspired policymakers today of “moral hazard,” the notion that any policy that assists those suffering some misfortune will weaken their moral fiber and make it more attractive in the future for them to act in a way that brings about that misfortune. Moral hazard played a large role in the U.S. 503

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congressional debate in 2013-14, for example, over extending long-term unemployment benefits. Opponents of the extension were convinced that such benefits merely remove all incentive to go out and find work.18 It is typical of the way economism operates that these opponents stated their conclusion as selfevidently true and ignored empirical evidence that showed that there are simply not enough jobs and that most of the unemployed are diligently seeking whatever work is available.

omism-type thought. On the one hand, economism claims to be nothing but the hard-headed application of mathematically precise economic laws, and therefore immune from reasonable criticism. On the other hand, defenders of economism, when challenged with contrary empirical evidence, typically deny the evidence with all the fervor of religious zealots whose faith has been challenged. Whenever it seems that the market must surely have failed, such as with the Great Recession of 2008, the reply always comes back that the market didn’t fail at all; we simply have never created the ideally “free” market because we always have These historical roots in religion help to explain allowed some vestige of the hated the internal contradictions one commonly government regulation to remain in sees in economism-type thought. On the one place.22 This slipperiness makes it all the more difficult for ethics to address hand, economism claims to be nothing but the the claims and policies offered by the hard-headed application of mathematically ideology of economism.

precise economic laws, and therefore immune from reasonable criticism. On the other hand, defenders of economism, when challenged with contrary empirical evidence, typically deny the evidence with all the fervor of religious zealots whose faith has been challenged. Economism was also influenced by the religious tradition that evolved in America as Calvinist beliefs were modified into Puritanism and eventually became the pattern of thought that the pioneering sociologist Max Weber termed the “Protestant ethic.”19 This religious belief system began with the ideas that whether a person’s soul was headed for heaven or hell was predestined, and that God’s grace would irresistibly reveal itself among the elect who were to be saved. Since Calvinism taught that earthly endeavors, including work, were among the ways that humans could contribute to God’s glory, success in business eventually came to be viewed as a sign of God’s favor.20 Economism thus has inherited from its Puritan-Protestant roots the general attitude that social policies that favor the rich are good. We have now had several decades to survey what happens when tax cuts for the wealthy are implemented as a way, purportedly, to increase jobs and general economic activity, and the data seem clear that it simply does not work.21 Yet defenders of economism continue to call for tax cuts for “job makers,” again as if it were self-evidently true that such policies need no justification. These historical roots in religion help to explain the internal contradictions one commonly sees in econ504

Economism’s Health Consequences

I lack space here to discuss in detail the track record of economisminspired policies. The brief summary is that economism has led to a serious worsening of income inequality in the U.S., and greater income inequality, impoverishment, and environmental degradation across the world.23 At least two aspects of this track record ought to be of concern for health care ethics. First, we have come to appreciate that the health care system is actually responsible for a relatively small component of the overall health of the population, and that what are called the social determinants of health play a much larger role in determining the overall health status of the population. A nation whose policies are shaped by economism typically neglects these social determinants. Poverty, poor education, and pollution, for example, all affect health, and have a multiplying impact on the health of the least-advantaged populations.24 Economism directs policy away from social programs that would correct these factors and thereby improve the health of vulnerable communities. Those who can afford it may live in safe neighborhoods in good housing free of rats and roaches, send their children to good schools, and breathe clean air. Those who cannot afford to purchase these goods as market commodities are deemed undeserving of them, and hence their increased rates of illness are viewed as their own responsibility. Second, among the social determinants of health, income inequality itself ranks high.25 That is, a socijournal of law, medicine & ethics

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ety with greater income inequality will be less healthy overall than a society with less inequality, even if the absolute status of the poorest segment of the population in the first society is better than that of the poorest in the second. Among the social problems directly associated with income inequality, Wilkinson and Pickett cite evidence for mental illness, obesity, teenage pregnancy rates, lowered life expectancy, and crime. They further analyze the data to show that it is most likely that income inequality is independently the driver that causes all these ill effects, and is unlikely to be merely a marker for some other, as-yetunidentified variable.26 Since economism has been a major driver of income inequality both in the U.S. and globally, it follows that economism is a direct threat to population health. As important as these considerations are for the ethics of health care, the intended focus of this paper is narrower. My main concern is what happens when one treats health care services strictly as a commodity to be bought and sold in the marketplace. I will return to that concern, merely noting that the importance of economism for health extends far beyond that narrow topic area.

Commercialization of Health Care I can perhaps best summarize my main thesis, within its narrower focus on the health care system specifically, by telling an anecdote about two conferences. In 2012, the Lown Institute in Boston sponsored a conference called “Avoiding Avoidable Care.”27 The focus of that conference was the general problem that had been addressed particularly by the Choosing Wisely campaign of the American Board of Internal Medicine Foundation.28 “Avoidable Care” referred to the growing consensus that far too many procedures, diagnostic tests, and medications are today administered in the U.S. despite scientific evidence indicating their lack of benefit for patients. This causes two problems. Financially, as much as 30 percent of the American health care budget is estimated to be consumed by this nobenefit category, diverting this massive sum of money — more than enough to insure all Americans now lacking coverage — from beneficial uses.29 The second problem, which Choosing Wisely elected to highlight, was the problem for the quality of care, since many interventions that offer no benefit nevertheless carry a significant risk for harm. It seems clearly unethical to expose patients to this risk of harm when there can be no (scientifically based) hope for a compensating benefit. A good portion of the discussion at the “Avoiding Avoidable Care” conference dealt with the barriers to eliminating these no-benefit interventions. (Some the buying and selling of health care • winter 2014

protested that “Avoidable Care” was an oxymoron and a better term was needed.) Failures in medical education came in for criticism. But, predictably, a good part of the discussion of barriers focused on commercial pressures. If, as estimated, some $640 to $750 billion is spent annually in the U.S. on no-benefit interventions, then all that money goes into someone’s pocket, and “someone” would predictably be loath to part with that revenue stream. Most of those “someones” are making enough money to be able to afford to lobby vigorously with payers and regulators, and to influence what is conveyed in medical education and in the medical literature, in a way that favors the status quo. By December 2013, when the Lown Institute sponsored the follow-up conference, two things had changed. One was signaled by the new title, “From Avoidable Care to Right Care.”30 Avoiding overuse of unnecessary interventions was seen now as only one part of the agenda. At the same time that well-insured patients might be subjected to overuse, those with poor coverage were often failing to get appropriate and vitally needed health services, as indicated by calculations that as many as 44,000 Americans die each year directly as a result of lacking insurance.31 “Right Care” for all, avoiding both overuse and underuse, was now the focus. The second point was reflected in a recurring theme throughout the conference, the claim that the U.S. no longer has a health care system, but instead has a revenue extraction system. What was meant by this claim had been previously crystallized by Philips: “The US health care industry is currently configured not to deliver care to individuals or health to communities but to deliver wealth to corporations.”32 The implication drawn from this claim, according to most speakers, was that tinkering around the edges of the health system with minor “reforms” would do no good. If “Right Care” was to be given to all patients, only wholesale reconstruction of the entire system would suffice.

Economism and Commercialization of Health Care The prescriptions offered by the “Right Care” campaign might or might not be valid. The main concern for health care ethics ought to be that they would receive a fair hearing and reasoned assessment. In a society in which the dominant political-policy ideology is economism, can such a fair hearing be obtained? I argued earlier that one of the main theoretical problems with P4P was that it seemed contrary to the dictates of professionalism in health care. Economism would address this conflict by dismissing professionalism. By saying that health professionals should be guided by their dedication to the interests of the 505

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patient, rather than by their individual financial (and other) interests, professionalism sets itself up as claiming an alternative source of values beyond the marketplace. This, according to economism, is illegitimate. What is in the interests of patients is determined precisely, and only, by what (presumably well-informed) purchasers choose to spend their money on in the “free” health care marketplace. It is intolerable hubris, on the part of providers, to presume to know better than the market itself what is in anyone’s interests.33 In an environment in which economism gets to set the rules for debate, a careful discussion of the pros and cons of P4P seems unlikely. We are less likely to

supercomputer capable of processing in real time the information from all the billions of market exchanges occurring globally, can know those things.36 It hardly matters that The Market that has these superhuman qualities exists only as a theoretical postulate. Ethicists are near the top of the list of those who must be put in their place and reminded that only The Market can know the answers to the questions that they pose. If, today, the health care market does not work in the ideal way claimed for it, it can be for only one reason — the health care market is not “free” enough. All vestiges of government regulation, and any other nonmarket intrusions, must be removed, and only then

I believe that economism is a deeply flawed ideology, but that is not the main point of my argument. If economism were openly proposed as a guide to policy, we could debate its pros and cons as compared to alternative frames of thinking. My main critique of economism is that it is not proposed; it is assumed to be self-evidently true as a matter of common sense. As such, it now generally escapes critical reflection and analysis. So long as one of our society’s central ideologies is thus protected from reasoned scrutiny, health care ethics cannot address the most critical issues raised by commercialization. My goal is to open the conversation about economism as an important component of doing ethical work about health care. appreciate that P4P may produce more “gaming the system” than real improvements in the quality of health care, as practitioners focus narrowly on how to get their reported numbers to look better and ignore the actual needs of patients.34 We are likely to ignore warnings from other fields such as K-12 education, where efforts to demand accountability by treating human-service professionals as cogs in an industrial apparatus have led to worse outcomes for students.35 I have noted the tendency, among economism advocates, toward a sort of doublespeak. Mirowski claims that this is quite a deliberate strategy and is adopted sincerely rather than cynically. When experts speak apparently out of both sides of their mouths, this creates confusion and doubt among the laity. Confusion and doubt, according to economism, is a healthy state of affairs. It is not merely that tactically, doubt undermines democratic engagement and leads the populace to turn control over to the market’s technical experts. Rather, there is simply no way that mere humans can fully comprehend the most important questions about how society should be managed and toward what ends. Only The Market, conceived as a sort of 506

will the interests of patients (as well as of providers, and everyone else) be ideally served. Under economism, “commercialization” of health care simply cannot be an ethical problem. The only solution for any issue in health care, just as with any other aspect of our social lives, is to turn it over completely to market competition. If we do not like the quality of health care, we must institute P4P. If we have problems with the uninsured, the solution can never be expansion of insurance by government; rather we must (for example) allow health insurers to compete across state lines, believing devoutly (regardless of the evidence) that such competition will automatically solve the problem. No matter what the difficulty, the answer is less government regulation and lower taxes on the wealthy and on corporations. In 2006, Callahan and Wasunna produced a carefully researched volume on Medicine and the Market.37 They surveyed health systems globally and concluded that there were no existing models that demonstrated superior outcomes, in terms of population health or efficiency, as a result of using market mechanisms in health system design. They then made the sensible journal of law, medicine & ethics

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recommendation that any effort to improve health care by turning some component of the system over to market forces ought to be viewed as an experiment. Their global survey turned up a lot of policy analysts who argued that health systems ought to be made up of a mix of market competition and governmental regulation, and who disagreed among themselves over how best to balance the two. They added, however, that in only one nation, the U.S., could they find any significant number of “experts” who claimed that the best way to provide health care is solely through market mechanisms with an absolute minimum of government interference. A number of health policy commentators in the U.S., notwithstanding Callahan and Wasunna’s findings, have concluded that the only health financing system that makes efficiency and cost sense is some variant of a single-payer system. Many bioethicists have argued that it is unconscionable for a country as wealthy as the U.S. not to provide guaranteed access to basic health care to all citizens — which would presumably require something akin to a single-payer plan to implement. (Thus far, no one has proposed a purely market-based financing plan that would guarantee health coverage to all Americans.) Despite this, when health reform was before Congress for active debate in 2009-10, virtually no politicians were willing to give any consideration at all to a single-payer proposal. It appears that so long as economism remains the reigning ideology that controls our political discourse, a policy course favored by many bioethicists and policy experts cannot even gain a hearing.

Conclusion I believe that economism is a deeply flawed ideology, but that is not the main point of my argument. If economism were openly proposed as a guide to policy, we could debate its pros and cons as compared to alternative frames of thinking. My main critique of economism is that it is not proposed; it is assumed to be selfevidently true as a matter of common sense. As such, it now generally escapes critical reflection and analysis. So long as one of our society’s central ideologies is thus protected from reasoned scrutiny, health care ethics cannot address the most critical issues raised by commercialization. My goal is to open the conversation about economism as an important component of doing ethical work about health care. References

1. L. A. Petersen, L. D. Woodward, and T. Urech et al., “Does Payfor-Performance Improve the Quality of Health Care?” Annals of Internal Medicine 145 (2006): 265-272; S. K. Houle, F. A. McAlister, and C. A. Jackevicius et al., “Does PerformanceBased Remuneration for Individual Health Care Practitioners

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Affect Patient Care? A Systematic Review,” Annals of Internal Medicine 157 (2012): 889-899. 2. D. M. Berwick, “The Toxicity of Pay for Performance,” Quality Management in Health Care 4 (1995): 27-33. 3. A. Qaseem, V. Snow, A. Gosfield, et al., “Pay for Performance through the Lens of Medical Professionalism,” Annals of Internal Medicine 152 (2010): 366-369. 4. See for example S. Hettiger, P. Natinsky, and J. Neller, “The Effect of Payment Reform on Physician Practices: Part 1: The Shift from Fee-for-Service to Outcomes-Based Reimbursement,” Michigan Medicine 111, no. 5 (2012): 14-18. 5. P. Ekins and M. Max-Neef, eds., Real-Life Economics: Understanding Wealth Creation (New York: Routledge, 1992); T. Teivainen, Enter Economism, Exit Politics: Experts, Economic Policy, and the Damage to Democracy (New York: Zed Books, 2002). 6. H. Brody, The Golden Calf: Economism and American Policy (CreateSpace/Amazon, 2011); H. Brody, “Bioethics, Economism, and the Rhetoric of Technological Innovation,” in M. J. Hyde and J. A. Herrick, eds., After the Genome: A Language for Our Biotechnological Future (Waco, TX: Baylor University Press, 2013): 177-191. 7. D. Harvey, A Brief History of Neoliberalism (New York: Oxford University Press, 2005); P. Mirowski, “Postface: Defining Neoliberalism,” in P. Mirowski eds., The Road from Mont Pelerin: The Making of the Neoliberal Thought Collective (Cambridge, MA: Harvard University Press, 2009): 417-455. 8. M. R. Somers, Genealogies of Citizenship: Markets, Statelessness, and the Right to Have Rights (New York, Cambridge University Press, 2008); M. J. Sandel, What Money Can’t Buy: The Moral Limits of Markets (New York: Farrar, Straus and Giroux, 2012); T. Frank, One Market under God: Extreme Capitalism, Market Populism, and the End of Economic Democracy (New York: Anchor Books, 2001). 9. D. Gasper, The Ethics of Development (Edinburgh: Edinburgh University Press, 2004). 10. P. Mirowski, Never Let a Serious Crisis Go to Waste: How Neoliberalism Survived the Financial Meltdown (New York: Verso, 2013). 11. See Somers, supra note 8, at 73-74. 12. See Sandel, supra note 8. 13.  Id., at 10-11. 14. K. Polanyi, The Great Transformation: The Political and Economic Origins of Our Time (Boston: Beacon Press, 2001). 15. See Brody, Golden Calf, supra note 6; M. Weber, The Protestant Ethic and the Spirit of Capitalism, trans. T. Parsons (Mineola, NY: Dover, 2003). 16. See Brody, Golden Calf, supra note 6; G. Bigelow, “Let There Be Markets: The Evangelical Roots of Economics,” Harpers Magazine 310, no. 1860 (2005): 33-38. 17. B. Hilton, The Age of Atonement: The Influence of Evangelicalism on Social and Economic Thought, 1785-1865 (Oxford, UK: Clarendon Press, 1986). 18. See, for example, P. Morici, “Obama Blind to Facts on Extended Unemployment Benefits,” UPI Analysis, January 24, 2014, available at (last visited November 10, 2014). 19. M. Weber, The Protestant Ethic and the Spirit of Capitalism, trans. T. Parsons (Mineola, NY: Dover Publications, 2003). 20. L. Ryken, Worldly Saints: The Puritans as They Really Were (Grand Rapids, MI: Zondervan, 1986). 21. J. Chait, The Big Con: The True Story of How Washington Got Hoodwinked and Hijacked by Crackpot Economics (Boston: Houghton Mifflin, 2007). 22. See Mirowski, supra note 10. 23. J. Cassidy, How Markets Fail: The Logic of Economic Calamities (New York: Farrar, Straus and Giroux, 2009); P. B. Smith and M. Max-Neef, Economics Unmasked: From Power and Greed to Compassion and the Common Good (Totnes, Devon, UK: Green Books, 2011).

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S Y MPO SIUM 24. M. Powers and R. Faden, Social Justice: The Moral Foundations of Public Health and Health Policy (New York: Oxford University Press, 2006). 25. I. Kawachi and B. P. Kennedy, The Health of Nations: Why Inequality Is Harmful to Your Health (New York: New Press, 2002); R. Wilkinson and K. Pickett, The Spirit Level: Why Greater Equality Makes Societies Stronger (New York: Bloomsbury Press, 2009). 26. Id. (Wilkinson and Pickett). 27. See (last visited November 10, 2014). 28.  H . Brody, “Medicine’s Ethical Responsibility for Health Reform—the Top Five List,” New England Journal of Medicine 362 (2010): 283-285; C. K. Cassel and J. A. Guest, “Choosing Wisely: Helping Physicians and Patients Make Smart Decisions about Their Care,” JAMA 307 (2012): 1801-1802; see also (last visited November 10, 2014). 29. Id. (Brody); D. M. Berwick and A. D. Hackbarth, “Eliminating Waste in US Health Care,” JAMA 307 (2012): 1513-1516; V. R. Fuchs and A. Milstein, “The $640 Billion Question—Why Does Cost-Effective Care Diffuse So Slowly?” New England Journal of Medicine 364 (2011): 1985-1987.

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30. See (last visited November 10, 2014). 31. A. P. Wilper, S. Woolhandler, and K. E. Lasser et al., “Health Insurance and Mortality in US Adults,” American Journal of Public Health 99 (2009): 2289-2295. 32. W. R. Philips, “Questioning the Future of Family Medicine,” Family Medicine 36 (2004): 664-665, at 664. 33. See Mirowski, supra note 10. 34. S. Woolhandler, D. Ariely, and D. U. Himmelstein, “Why Pay for Performance May Be Incompatible with Quality Improvement: Motivation May Decrease and Gaming the System Is Rife,” BMJ 345 (2012): e5015. 35. D. Malina, “Performance Anxiety—What Can Health Care Learn from K-12 Education?” New England Journal of Medicine 369 (2013): 1268-1272. 36. See Mirowski, supra note 10. 37. D. Callahan and A. J. Wasunna, Medicine and the Market: Equity v. Choice (Baltimore: Johns Hopkins University Press, 2006).

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Economism and the commercialization of health care.

Those concerned over the excessive commercialization of health care, to the detriment of both professional and patient-centered values, commonly propo...
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