01carey600It was my hope that by this time we would have help from the feds to enhance primary care training, changes in residency funding to direct money to primary care departments, and management fees which would help us to pay for the care we deliver to our 750 diabetic patients among other things. Instead, we are in the middle of what appears to be a rather mean-spirited discussion regarding the age-old question of just who is my brother’s keeper.This has gotten me to thinking about the problem of the commons

Garret Hardin described a scene in an English common pasture “Picture a pasture open to all. It is to be expected that each herdsman will try to keep as many cattle as possible on the commons.” He then describes his vision of what will happen if all are allowed access unchecked.  “Adding together the component partial utilities, the rational herdsman concludes that the only sensible course for him to pursue is to add another animal to his herd. And another; and another…. But this is the conclusion reached by each and every rational herdsman sharing a commons. Therein is the tragedy. Each man is locked into a system that compels him to increase his herd without limit–in a world that is limited. Ruin is the destination toward which all men rush, each pursuing his own best interest in a society that believes in the freedom of the commons. Freedom in a commons brings ruin to all.”

Garrett has since been somewhat discredited. It is not clear that the resources as they appeared limited were so in actuality. This seems to be, however, the fear of the Republicans with healthcare. They seem convinced (and I have to admit that there is some evidence to support this) that those who are now uninsured (and have no current access to the commons) once given access will consume unlimited resources. Interestingly, they feel like those who now receive Medicare are entitled to unlimited access to the health care commons…an interesting stance.

What is really interesting is that Ezekiel Emanuel has been accused of formulating “death panels” as a solution to the problem of the healthcare commons. What has articulated is a way out of this problem of the commons. He clearly believes (as do I) that a certain amount of the “health care commons”  should belong to all of us. To solve the problem of overuse, he suggests that we would have to select what is included in our “commons”. If we don’t want to be in a group that funds terminations for example, we don’t select that group. I would like to see this further articulated as it seems preferable over people who have no money for health care dying in the street to me.