[The Montana Professor 15.1, Fall 2004 <http://mtprof.msun.edu>]

Notes from the Editor's Desk

Richard Walton
Philosophy
UM-Missoula

Board meeting

The annual meeting of the Board of Directors of The Montana Professor, Inc. was held April 10th on the UM-Missoula campus. Several new members of the Board were elected and introduced. Victoria Cech of Billings rejoins the Board after an absence of two years. Formerly associated with MSU-Billings and Rocky Mountain College, Victoria now heads up patient education efforts at St. Vincent Hospital. William Locke of MSU-Bozeman adds important expertise in the sciences to the Board. Kate Shanley, Native American Studies, and Linda Gillison, Classics, of UM-Missoula also join us. The Board of Directors of the corporation also serves as The Montana Professor's Editorial Board.

Taryn Hart of Church, Harris, Johnson and Williams, the corporation's legal counsel, led the Board through a number of housekeeping changes in the Articles and Bylaws. Aside from such minor matters as changes in titles for the editorial staff and modifying certain requirements to take into account the realities of travel in Montana, the firm's recommendations bring us into compliance with standards of best practice for Montana non-profit corporations. Church, Harris, Johnson and Williams has been immensely helpful to us.

This issue

We follow up our interview with Board of Regents Chairman John Mercer (Spring 2004) with an interview with Sheila Stearns, newly appointed Commissioner of Higher Education. Readers will find Commissioner Stearns' views on her position and the Montana University System of great interest. Our Spring 2004 issue also contained an article by MSU-Bozeman Regents Professor Jack Horner which many readers will remember well. We follow it up in this issue with an article on learning disabilities in higher education by UM-Missoula's Director of Disability Services for Students, Jim Marks. Like some other readers in the field of disability services from whom we heard, Marks found Horner's remarkable story inspiring. He was pleased to be able to write in response. The second part of Henry Gonshak's two part review essay on the war against terrorism opens our book review session. He has invested a great deal of careful, searching thought in this very timely essay. We look forward to readers' responses to Henry's arguments.

The other articles and reviews in this issue bear no thematic relationship to the contents of last spring's journal. We trust that readers will find them topical, nevertheless. We do begin a two part article in this issue, Laurence Berger's "Sailing Into Retirement." Look for the second part in the spring.

An issue of importance

Two items in the following pages assumed particular interest for your Editor last May. The efforts at improving my health that I described in this column last fall proved to be too little, too late, and perhaps misdirected. Golf, after all, is a game to be taken seriously only by the athletically gifted. For those of us of ordinary talents (or less) foolish enough to think we ought to be able to play well, golf can be a bountiful source of stress and aggravation. In any case, in mid-May what appeared to be a case of lingering bronchial inflammation proved upon closer examination to be angina pectoris, and I found myself undergoing urgently needed surgery.

I had read Stewart Justman's Seeds of Mortality only a few weeks before experiencing my own confrontation with mortality. In the months following the surgery my thoughts turned often to passages from this profoundly insightful and moving book. One can readily understand why the book has gained national acclaim. Ernelle Fife of SUNY-New Paltz reviews Seeds of Mortality in our reviews section.

We accepted Lewis Petrinovich's "Health Care in a Just Society" because of the alarming trajectories MUS employee health insurance benefits and costs have followed over the last several years. Employee costs have increased while the coverage has decreased. The State's contribution has not nearly kept pace with the increase in costs. To my great dismay I learned in the days following my release from the hospital that MUS employees in the Missoula area have even less insurance coverage than those obtaining their health care services elsewhere in the state. Two groups of Missoula physicians have refused to contract with Blue Cross Blue Shield, the company which manages MUS health insurance. Consequently, BCBS benefits for services from these physicians are less than for those with whom BCBS has agreements and the out-of-pocket expense to patients is more(apparently, much more. Most unfortunately, these groups have virtual monopolies on their specialties in Missoula by virtue of exclusive contracts with the local hospitals. According to an account in the Missoulian newspaper of May 23rd, the physicians did not feel themselves adequately compensated for their services under the terms BCBS offered.

BCBS recently filed suit against one of these physicians' groups in Federal Court in Butte, alleging monopolistic practices whose effect is to drive up costs to BCBS policyholders and other patients. The reaction has been remarkable to behold. Two or three other physicians' groups have cancelled their agreements with BCBS in protest of what they describe as "bullying" tactics. In defense of the physicians the CEO of another health insurance management company has stated that physicians' fees should not be determined by insurance companies, but "by the free market." Apparently this gentleman's conception of the free market would not pass muster with Adam Smith. We may hope that it does not pass muster with federal law, either.

American medicine has long regarded itself as operating on the free market model, physicians and medical institutions functioning as entrepreneurs. Efforts toward establishing a universal healthcare system, like that of Canada, or those of European countries, have been resisted ferociously. But we do not--and could not--fairly distribute the core services of modern healthcare through a classical free market. From the point of view of physicians and hospital managers we do not have a free market because of the power of the major payers, governments and large insurance companies. From the point of view of consumers, the patients, the free market model fails because we have little choice or bargaining power. Desperately ill or injured persons do little comparison shopping for medical services, and even those needing only routine treatments would find it difficult. I have visited many physicians' offices, and worked with medical people professionally for several years, and I have never seen a schedule of fees. On the other hand, I have several times been told that physicians are entitled to charge whatever they like for their services.

There is a fact about medical needs that offers them some support in that belief. More importantly, it shows, in my opinion, why the core medical services cannot be properly distributed through a free market. In Book V of his Nicomachean Ethics Aristotle argues that justice is the bond that holds societies together, and justice requires reciprocal and proportionate exchange between citizens. He famously notes that to make such exchanges possible money is required to serve as a medium. Money, however, will function as a medium of exchange for goods of differing kinds (e.g., houses and shoes) only where the two goods are commensurable. Yet the goods of medical services are often of immeasurable value--priceless. Even if physicians and medical institutions were open about their charges and amenable to bargaining, the person in need of cardiac surgery, or even the reduction and stabilization of a femoral fracture, would lack the conceptual apparatus necessary for playing his free market role in setting prices. Thus, if justice is to be achieved in this area, some other means of determining fair charges will have to be found.

If I came away from my recent experience as a critical care patient believing that physicians' fees are sometimes too high, I came away entirely convinced that nurses' salaries are too low. American medicine stakes its reputation for quality largely on the medical miracles that its physicians--especially its surgeons--are able to perform. It is too seldom noticed, however, that surgical patients would often expire of the surgery's effects if abandoned when the surgeons had completed their work. Expert, faithfully attentive nursing care is as necessary as the surgery itself in effecting major surgery's benefits. "Care" has become a term of art in American medicine: we now talk about "the healthcare industry." What patients frequently need, however, is authentic care. That is what I received from most of my physicians, and especially from the St. Patrick Hospital nurses. Early one morning near the end of my hospital stay the nurse who had attended me through the two previous nights came into my room and announced that her shift was ending and she would be off for the next two days. "You are doing so well that I think you will be gone when I return, so I want to say goodbye now" she said. Then she bent over my bed, embraced me and wished me well. That, too, was priceless care.

[The Montana Professor 15.1, Fall 2004 <http://mtprof.msun.edu>]