Choice, Equality and Cost
Chapter 6: The practitioner
Rawls writes as follows about the doctor who makes an interpersonal comparison of a dish that the diner had never ordered: On birthdays we give things that we know are wanted, or that will please, to express affection; our gifts are chosen in the light of intimate knowledge and shared experiences. But doctors are expected to assess the situation of their patients, and teachers to judge their students, on an entirely different basis … Doctors consider their patients’ medical needs, what is required to restore them to good health and how urgent their treatment is. (Rawls, 1982: 172) On birthdays we go by wants. The metric of goal attainment is the recipient’s personal preference. Surgery, however, depends on need. Need is a structural imperative that cannot be skimped if the function or role is to survive. Need is the precondition for want. Doctors are skilled specialists schooled in need-satisfaction. The consumers are not. It is the duty of the physician to fill the epistemological vacuum. Medical paternalists have asserted that health care is too important to be delegated to the body-holder: ‘Only the doctor knows what good doctoring is’ (Horder, quoted in Johnson, 1977: 74). Liberal individualists are less convinced that the division of labour must inevitably mean delegation and dependence. Even the ill-informed have ideas and perceptions which they can bring to the table. Even the well-informed can slip into waste and beyond that into duplicity. This chapter is about the well-informed.
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