On Rule By Experts, Or, The New Barbarism

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Paul Greenberg

On Rule by Experts, or: The New Barbarism

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Sign-Up Buried in the mass of directives issued by the new head of the Center for Medicare and Medicaid Services was a little ol' regulation putting the government in the business of end-of-life consultations. Or what Sarah Palin in one of her unseemly flights of candor referred to as "death panels." But as soon as this regulation came to light, and the public reacted, not at all favorably, it was the regulation whose end had to be hastened.



It's not just that the new provision was issued without the approval of Congress -- indeed, Congress refused to pass it after strenuous objections were voiced -- but the official who issued it, Dr. Donald Berwick, didn't have to win congressional approval himself.



Dr. Berwick's was a recess appointment, which means he didn't have to subject his record to the kind of scrutiny other presidential appointees get. So his views didn't attract much public attention until he had taken office and started issuing edicts like this one. Call it a stealth regulation from a stealth appointee.



Daniel Henninger of The Wall Street Journal went through a number of the good doctor's speeches, and came up with a number of quotes that would surely have raised warning flags if they'd come to public attention in the course of confirmation hearings. But there were no hearings. If there had been, the good doctor's ideas about how to improve American health care would have appealed only to those who believe in government of, by and for experts. Consider these gems:



"I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do."



"Indeed, the Holy Grail of universal coverage in the United States may remain out of reach unless, through rational collective action overriding some individual self-interest, we can reduce per-capita costs."



"A progressive policy regime will control and rationalize financing -- control supply."



"Young doctors and nurses should emerge from training understanding the values of standardization and the risks of too great an emphasis on individual autonomy."



The emphasis in all these statements is certainly not Dr. Berwick's. Indeed, by avoiding confirmation hearings, he avoided emphasizing any of his views. Just as he kept this new Medicare regulation under his hat till he was ready to spring it on the country. Why let the rest of us know? It's only a matter of life and death. And when it comes to such things, doctor knows best. At least if he's the doctor.



Anyone reading Dr. Berwick's statements has to be struck by his pervasive suspicion of individual autonomy and his enthusiasm for rule by experts like himself. (Patients just get in the way.) He seems oblivious to the oxymoron inherent in the concept, rational collective action. A mob, after all, is a collective, but that scarcely makes it rational. The doctor slips into euphemism by habit, preferring to control supply rather than ration health care, which is what controlling its supply amounts to.



Dr. Berwick is representative of the Culture of Expertise that abhors individual choice (irrational!) and so would turn over such decisions to an elite of experts. He sounds like the very embodiment of the new paternalism that comes with a populist gloss.



Ortega y Gassett, the Spanish philosopher, essayist and thinker in general, saw all this coming. He called it the barbarism of specialization, and Dr. Berwick's specialty is medical cost-accounting. He is all too typical of a whole bureaucratic class. This species of barbarian has a title on the door, graduated from an Ivy League university, and couldn't write a sentence in clear, simple English prose if his life depended on it. Government offices and the halls of academe are full of such.



As for the elite that Donald Berwick would entrust with decisions about our health care, it need hardly be said that he and like-minded colleagues would compose it, they being the leaders whose business it is to make decisions for the rest of us, the poor uninformed, self-interested multitude. The doctor he brings to mind most is Dr. Strangelove.



Those of us who would prefer to make our own decisions, thank you, only disturb Dr. Berwick's well-ordered, efficient, standardized, rationalized, collectivized and above all impersonal system. His statistical sanitarium is geared to treat the average patient, who doesn't exist. At least I've never met him, any more than I've met that other abstract concept, the average man. Have you?



With Dr. Berwick, it's the numbers that count, not the kind of values that cannot be quantified, however real. Like life itself. There was something neither humane nor human about his turgid new directive. The good doctor is the very model of modern man in that respect, believing that what matters is the system, not the individual. And like modern man, he can be frightening to behold.





Paul Greenberg