Jtournal ofMedical Ethics 1997; 23: 71-76

Morality, consumerism and the internalmarket in health careTom Sorell, Department of Philosophy, University ofEssex

AbstractUnlike the managerially oniented reforms that havebrought auditing and accounting into such prominencein the UK National Health Service (NHS), and whichseem alien to the culture of the caring professions,consumerist reforms may seem to complement movestowards the acceptance of wide definitions of health, andtowards increasing patient autonomy. Theempowerment favoured by those who support patientautonomy sounds like the sort ofempowerment that issometimes associated with the patient's charter. For thisreason moral criticism of recent NHS reforms may stopshort of calling consumerism into question. This,however, would be a mistake: consumerism can beobjectionable both within and beyond the health caremarket.

The reforms in the National Health Service reflecttwo goals of policy-making in the UK. One is thecontainment of public expenditure; the other is thepromotion of personal responsibility, private owner-ship and entrepreneurship. Over the past fifteenyears both goals have been pursued by enlarging thesphere of the market economy, and by popularisingone understanding of the individual's place withinthat economy. Sometimes the sphere of the marketeconomy has been enlarged by privatising publicsector activity - selling publicly-owned businesses orcontracting out publicly-supplied services. In thesecases, different branches of the public sector havebeen transferred outright to the market economy. Inother cases the strategy has been to simulate themarket. This is where the NHS fits in. Although itsactivities continue to be paid for out of generaltaxation, salary deductions, and, to a much smallerextent, user-charges, their efficiency is determined,at least in theory, by a strict purchaser/provider splitmodelled on the split between buyer and seller onthe open market.

In theory, providers compete for patients, and thecompetition, at least at the level of hospitals, drives

Key wordsUK National Health Service; internal market; patient'scharter; patient's rights; insurance.

down prices and raises the quality and supply of treat-ment. Prices are also supposed to be driven down byfreeing up the labour-market in health care, allowingsavings to be made according to regional variations inthe cost of living and rates of unemployment. For thesystem to work as intended, the costs of labour andcapital and the effectiveness of treatment need to bemonitored in great detail, and measures of perfor-mance have to be agreed and widely adopted. Manyof the moral problems with the internal market arisefrom what is involved in monitoring cost and measur-ing performance, rather than from something morallyquestionable in the policy of getting value for moneyitself. It is not as if getting value for money is econom-ically important as opposed to morally important. It isboth. The NHS discharges an urgent moral obligationto relieve pain and treat disease and to promote fullyfunctioning human life: the more treatment can beprovided from fixed or shrinking budgets, the morepain and disease can be treated and full functioningpromoted, at least in principle. If the reformedNHS, with its internal market, is more efficientthan the NHS with government-imposed cash limitsthat operated in the early 1980s, then that is anargument - a moral argument as well as an economicargument - for the reformed NHS.

Yet the morally important goal of making budgetsstretch further may itself have moral costs. The NHSrelies on the skills and commitment of a vast numberof health care professionals and allied workers.Maintaining their commitment and morale is expen-sive, and the main factor pushing this cost upwards israrely simple selfishness. When the poor pay of someNHS employees is kept low because public spendingtargets require it, that is a sign that people whose workis morally valuable are themselves the victims of afailure of distributive justice. The more the relief ofpain and suffering costs, however, the less relief canbe provided within limited budgets. Or at least, theless can be provided unless waste is rife. It is unlikelyto be clear whether waste is rife unless the costs ofproviding health carLare established, and unless thehealth care provided is known to be effective. Buthere, too, finding out costs and deciding on effective-ness is itself costly - costly in time and resources, andcostly in morale. Specialist skills are required to adapt

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72 Morality, consumerism and the internal market in health care

accounting and audit measures to health care. Theseskills are likely to be bought at rates of pay that dwarfthe pay of those who are closest to the patient and attimes responsible for the patient's life and death.Again, the diversion of health service money intoaccounting and audit is likely to appear self-defeating,since it depletes the funds that auditing and account-ing are supposed to allow to be used better for healthcare. The effort and resources put into audit andaccounting may make it appear as if the goal ofeconomic efficiency is hijacking the health service andmaking the doctors and nurses secondary to themanagers. What is perhaps worse, the measures usedin audit are likely to be disputed, so that energy thatought to be channelled into health care is divertedinto argument about projections and spreadsheets.Finally, medical staff may not only find the auditingand managerial culture alien; they may not have theskills or inclination to fall in with its demands. As aresult, they may feel demoralised enough, or alienatedenough, to leave health care altogether, therebyputting out of circulation skills that cost the state agreat deal to teach. The British Medical Associationhas recently reported an alarming increase in thenumber of GPs leaving medicine, and this hasoccurred concurrently with increased difficulties inrecruiting newly qualified doctors into generalpractice. The economic cost of demoralised, expen-sively trained people is also a moral cost, since it isanother instance of resources being taken away fromthe promotion of wellbeing.

Moral costsAgainst this background the economic and relatedmoral costs of reform may cancel out the economicbenefits of increased efficiency, desirable as thosebenefits are. Even if the costs are outweighed by thebenefits, the economic and moral complexity of real-ising the benefits is hard to exaggerate. And there arefurther, more specific economic and moral costs,arising from the way the reforms have been imple-mented in practice. Some of these have been pointedout in the recent literature by Alan Maynard,' CalumPaton,2 and Robert Royce,' and I do not propose tocover the same ground. Instead, I want to turn to theother goal of public policy-making that I am claimingis behind the NHS reforms: namely, the goals of pro-moting personal responsibility, private ownership andso forth. This goal has been pursued by popularising acertain understanding of the individual's relation tothe market: on the one hand, an individual is depen-dent on the market for his or her income and is underan obligation not to set his or her wage demands toohigh; on the other hand, the individual is encouragedto be a an exacting purchaser of services from themarket, and to make choices that are as informed aspossible. Call this the consumerist role of the individ-ual. The NHS reforms engage this role through apatient's charter, just as government reforms else-

where in the public sector engage this role throughother charters. These charters lay out the conditionsof service that consumers are either guaranteed or canusually expect the public sector to provide, sometimesbacked up by financial compensation in the event ofnon-performance.

Unlike the managerially oriented reforms thathave brought auditing and accounting into suchprominence in the NHS, and which seem alien tothe culture of the caring professions, consumeristreforms may seem to complement moves that arebeing made towards the acceptance of wide defini-tions of health, and towards increasing patientautonomy. Certainly the rhetoric of consumerism,with its emphasis on the words "choice" and"freedom" harmonises with talk of making treat-ment more sensitive to the choices of the patient4and harmonises also with talk of empoweringpatients by giving them more information. Theempowerment favoured by those who supportpatient autonomy sounds like the sort of empower-ment consumer groups often talk about. And to theextent that power seems to be transferred under theNHS reforms from hospital consultants to a widervariety of providers of primary care and patients, thereforms can give the impression of marching in stepwith measures that opponents of the governmentadvocate on moral rather than economic grounds.For this reason moral criticism of the NHS reformsmay stop short of calling consumerism into question.This, however, would be a mistake. As I shall nowtry to show, consumerism can be objectionable bothwithin and beyond the health care market.

IWe can say that a policy of providing a good orservice is consumerist when the receiver of the goodor service is regarded primarily as a paying customer,and when the provider subscribes to the precept thatthat the customer is always right, or that thecustomer is usually right, or that the customer has tobe treated as if he were always right. Treating thecustomer as if he is always right does not just meanbeing disposed to concede to the customer whenthere is a dispute between buyer and seller over whois right; it means gearing commercial practice tothings consumers are known to like, such as payingas little as possible or paying as late as possible.

It is hard not to have some sympathy with con-sumerism, for consumerist policies often benefit uswhen we are at the receiving end; and in the Westernworld practically everyone is at the receiving end ofgoods and services as a paying customer several timesa day. Again, in the free market, sellers are dependenton buyers who, if the market is working well, arealways free to choose the goods or services of a com-petitor. In order to get a competitive edge in such amarket, a seller may have to use more than the strategyof keeping the price low. The seller may have to

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Tom Sorell 73

accommodate the buyer in other ways, for example, inrelation to speed of delivery or terms of credit.Consumerism can thus be in the interest of sellers aswell as buyers in a competitive market. In the form ofconsumer protection regulations or consumeradvocacy, consumerism may also be a justifiedresponse to the inequality of sellers and buyers in somemarkets. The inequality may consist of an asymmetryof knowledge, or of financial strength, so that thebuyer is at risk of being manipulated into purchasing,or having to suffer serious damage or loss when some-thing goes wrong. So far, so good for consumerism.Nevertheless, it is not hard to think of cases where thecustomer is not right, and where catering to thecustomer's wishes might be cruel to a third party - asin the case of the market for videos showing sexualassault - or unjust to the provider of a service.

Small businessSome clear cases of unjust treatment of providers byconsumers come from the sphere of small business.5In small business buyer and seller need not be verydifferent from one another in financial strength orsophistication, so that the usual presumption infavour of the customer's.being the weaker party fallsaway, as does one ground for consumerism. Evenwhere the seller is big and profitable, it is possible forthe customer to take undue advantage, and thereforeact unjustly. For example, if a shopper buys a lamp ora rug on a whim and then becomes disenchanted withit though it is not faulty, it can happen that hedemands his money back. Shoppers may even inventflaws or claim that they were pressured into buyingwhen in fact they weren't. In such cases, the fact thatthe shop is large and profitable and can afford to takeback the goods does not make it right for the shop tobe asked to do so. It is no more right than if the refundwere demanded for negligently purchased goods froma kiosk on the verge of bankruptcy. Negligentshoppers cannot even be let off the hook entirelywhen the business they want the refund from has aconsumerist policy guaranteeing refunds. Forexample, in the UK, the department store group JohnLewis has a policy of giving refunds for goods so longas the request for a refund is not grossly unreasonable.This condition might be met where the imprudentshopper returns the rug or lamp. But that a refund forthe lamp or rug is permissible under the policy doesnot mean that the shopper was not negligent after all.It is like the case where one driver carelessly runs intoanother car whose owner happens to be forgiving.The forgiveness does not cancel out the negligence;and neither does a generous refund policy make it allright to ask for a refund for something that works per-fectly well but was bought thoughtlessly.

Patients can also be negligent and overdemanding,and clutch at consumerist policies to make them-selves appear to be in the right. If they demand to beseen by a GP without an appointment or call out a

doctor in the middle of the night without givingmuch thought to whether their condition is serious,then they are going in for a kind of behaviour thatcompares closely with unreasonable behaviour in thecommercial world, behaviour we have only to bereminded of to see that the customer is not alwaysright. Again, if a patient turns from one generalpractice register to another because the first practicewouldn't let him see a doctor without an appoint-ment, or because the first practice had too manywomen doctors, or because he did not like the toneof voice the doctor used when pointing out the con-sequences of continued heavy smoking, the patientmay very well be unreasonable, and it is unreason-able to encourage unreasonable patients to thinkthat they are always or usually right, just as it isunreasonable to encourage unreasonable John Lewiscustomers to believe that they are always right.We should also consider unreasonable lengths that

providers of services may be asked to go to in gettingor retaining business or in satisfying a customer orpatient. Accountants are sometimes given to under-stand by clients that they must disguise or condone afinancial irregularity in order to retain an account;doctors may be asked to provide a medical excuse foran absence from work ofa perfectly healthy patient, orto back up a claim for compensation with appropriatemedical evidence. Even where it would look like dis-loyalty not to back up the patient, even where not toback up the patient would lead to some therapeuticsetback, the misrepresentation involved might make itwrong to agree to the request. And if the patient weresupported, the justification there might be for doingso would have to come from the consequences forpatient wellbeing ofnot doing so, rather than from thestatus of patient as consumer.A different sort of case occurs where the patient

requires treatment that would have been unnecessaryif earlier medical advice had been followed, orrequires treatment that will only have a negligiblebenefit unless the patient changes his ways, forexample by eating or drinking or jogging less. Herethe patient is not asking the doctor do anything shady,but there are medical grounds against complyingunless the patient does his part as well. If the patientrefuses to do his part, or believes that the patient'spart consists of receiving treatment full stop and notcooperating with preventive measures, then perhapsthe doctor goes too far if he meekly treats the patientand the patient continues to jog, smoke or eat asmuch as before. That the patient might have his partto perform, his responsibilities in the medical relation-ship, is at least not emphasised in the UK patient'scharter: it is all about patient rights and expectations.

IIJust as consumerism in the commercial contextsometimes obscures or even excuses the over-demandingness of some consumers, so consumerism

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74 Morality, consumerism and the internal market in health care

adapted to patients may obscure or appear to excuse

the negligence and overdemandingness of patients.But second thoughts about consumerism cannot stopthere, because there are reasons to think that patientsare not consumers at all, or consumers of too unusuala kind, to be covered by any simple consumeristpolicy. First, the typical consumer is assumed to beadult, healthy, able to reason, informed or in a

position to become informed, and solvent. A patientneed be none of these things at the point at whichtreatment is necessary or has to be thought about.Second, an effective choice of a treatment or of a

doctor may require a grasp of specialised informationthat even a rational, healthy adult lacks the training tograsp. It usually takes less to make an effective choiceof a rug or lamp. Third, within the context of theNational Health Service the patient need not be a

paying customer in any sense. When he is a payingcustomer in some sense, that is, when he has a deduc-tion made from his salary every month, the paymentsare unrelated to the cost of a specific treatment hereceives if he receives any treatment at all. The priceof treatment is usually entirely unknown to thepatient, and is not a factor in his decisions about treat-ment, though it may be a factor in decisions aboutwhat treatments are proposed to him by his doctor.Finally, the people or institutions that the treatment isbought from do not face bankruptcy or even a signifi-cant loss of earnings if the patient is dissatisfied. In allof these respects, patients are either unlike con-

sumers, or else, because of the insensitivity of theirbehaviour to price, not enough like ordinary buyers inthe market to be called consumers of the same kind as

ordinary buyers.

No-claims bonusEven when the users of the health service have paidfor it through their general taxes or deductions fromtheir salaries, it is misleading to describe them as

buyers of a service on the model of retail purchasersof building work or a telephone connection. Theyare better described as contributors to a compulsorymass health-insurance pool. Participation in themass pool is compulsory in the sense that those whohave the means to contribute and are not in the blackeconomy are obliged to contribute. But contributorsdo not necessarily use the service, and users are notnecessarily contributors. What is more, contribu-tions are according to income or ability to pay ratherthan according to health risk. These facts distinguishNHS contributions even from contributions to otherinsurance pools. Unlike purchasers of commercialhealth insurance, contributors to the NHS do notpay according to lifestyles or genetic histories. Theydo not pay according to age or where they live orwhat they do for a living. This means that some

users, even paying users, are heavily subsidised byothers. Or, in other words, many contributors payheavily for other people's risks and other people's

treatment. Some contributors pay for that othertreatment knowing they will never use the NHSthemselves. It is the use of the service rather thanpayment for it that entitles one to enforce expecta-tions about the standard of service in the NHS. Thismakes the consumerism of the NHS very differentfrom consumerism of the ordinary kind.Not only does the NHS substitute a non-economic

category of user or patient for that of consumer; itshuns policies that are essential to consumerism in theinsurance industry. A leading consumerist practice inthe insurance industry is the award of a no-claimsbonus on premiums. People who have no record ofdrawing on an insurance pool for automobile colli-sions, for example, are allowed to make smaller andsmaller annual payments; when they do make a claim,this bonus is lost. Now commercial health insurancecannot operate quite the same sort ofno-claims policyas car insurance, since the risk of having to draw onthe pool increases with age and so with the length oftime there has been no claim made on the policy. Ahealth insurance policy that cut premiums to the non-claiming twenty-year-old until they were very lowindeed, and then kept them at that level until therewas a claim, could not sustain the big payouts thatwould be required when the policy-holder who hadnever yet claimed reached an age associated withexpensive illnesses. But commercial health insurancepremiums are adjusted to reflect relatively low-risklifestyles and occupations. From the angle of theprivate health insurance market, low-risk people whopay the same as high-risk people into the NHS poolare not getting their due as customers (a premiumthat rewards low-risk policy-holders), while those whonever pay and always use the NHS (sometimesbecause they smoke and drink far more than doctorsadvise) are getting a free ride at the expense of payingnon-users. From the angle of the commercial market,it is the free riders who should be paying, or perhapswho should be excluded from insurance altogether,since they do nothing to lower their health risks.

Principle of solidarityIfone finds this way ofthinking repellent, because onesubscribes to the principle of providing treatmentaccording to need and not according to means, thenone has also got to consider whether insurance con-sumerism, which generates this way of thinking, isreally at home in the NHS context, even thoughpayments for the NHS go into an insurance pool. Itmaybe that in the NHS, as opposed to the commer-cial health insurance funds, a principle of solidaritybetween paying non-users and non-paying users andeverybody in between has to be introduced. It may bethat a solidarity principle has also got to operate inenvironments where there is only commercial healthinsurance and people who would normally beexcluded from the pool because of the burden theywould impose on low-risk payers would thereby have

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Tom Sorell 75

no protection from catastrophic loss of income anddisability. It may be that where there is no other wayof providing medical help, it being a very fundamen-tal component of wellbeing, consumerist thinking hasgot to lapse. If that is right, and if the kind of goodmedical help is for a human being provides a directargument for having an insurance scheme geared tosolidarity, it is unclear that any further moral illumi-nation or power is added by talking of that humanbeing as a buyer or consumer of a service. The unre-vamped concept of a patient or the concept of apotential patient carries all the content one needs.The principle of solidarity needs a very different

perspective from the perspective of the patient'scharter. It does not focus narrowly on the relation ofpatients to providers, but on relations betweenpatients, and between patients and payers wherethese groups are different. It would be interesting toconsider what entries a patient's charter might havethat reflected these relations. People who eat ordrink themselves into hospital might have shortcom-ings as fellow contributors to a solidarity pool; andpeople who use up resources for conditions that arenot obviously health risks, such as infertility, mightalso flout the principle of treatment according toneed. Of course, other things are paid for out of theinsurance pool than medical conditions, for examplethe very large salaries of consultants and relocationexpenses for managers. Would people feel as com-fortable drawing these things from what they regardas a solidarity fund, albeit one they contribute to, asthey might drawing them from wealthy patients' feeson the private market?

Health and wealthI have been arguing that consumerism tends to mis-represent the NHS and the position of users withinit. Patients are certainly not the only ones withrights, and they have responsibilities to others in theNHS, not only to the doctors, but also to the payingnon-users or the paying light users. The paying non-users and the paying light users, for their part, arenot necessarily being taken advantage of by theothers, since the good they are subsidising for theheavy users is one that the people cannot do without.This is why solidarity is in order. It may be a kind ofbad luck that one is in a position to be a heavy payerat a time institutions exist to exact the payment fromyou. But it is not bad luck to be in the position ofbeing a heavy payer, or for one's resources to be usedto relieve the need for so basic a good. For in orderto be a heavy payer, one normally needs health andwealth, and one's wealth is normally far fromexhausted when one subsidises other people's healthcare through an insurance pool. From the perspec-tive of solidarity, the heavy non-users are lucky to beat such low risk and have a greater ability, as a result,to gain the income from which their contributionsare drawn. From a consumerist angle, on the other

hand, the heavy-paying non-claimants in an insur-ance pool are heavily exploited: they are beingcharged too much for protection against a small riskof ever having draw upon the pool themselves.

It might be objected that I have been too hard onconsumerism, since in the NHS context the effect ofit, or at least the intended effect, is the morally cred-itable one of getting providers to think more andmore about the wishes of patients, and less and lessabout making life easier for themselves. It might bethought that far from needing criticism, con-sumerism actually promotes treatment that showspatients more respect in the moralist's sense of"respect". Again, when the consumer is not the indi-vidual patient but the GP practice or the healthauthority, the consumerism of the reformed NHScan have the effect of producing a greater amount ofsynergy between providers and purchasers of aservice, with likely therapeutic benefits for patients.Surely this, too, must constitute a moral improve-ment over the old NHS?

I concede that the purchaser/provider split maybring about more coordination among GPs,hospitals and health authorities through the disci-pline of financial penalties for those who are carelessofpurchaser choice, but I doubt that consumerism isthe right medium for increasing respect for patientsin the sense of "respect" that is familiar in moraltheory. The standard basis in moral theory for moralrespect - namely the humanity or personhood of thepatient - is independent of, and logically prior to,any role a patient has as user or consumer of aservice. Moreover, treating someone primarily as auser or purchaser of a service need not reinforcerespect for persons, since it might emphasise theeconomic value that a patient offers - the increase inpractice size and income - rather than the value of aperson. Again, in morality respect is a two-waystreet, as appropriate, other things being equal, tothose who give as to those who receive treatment.But in consumerism purchaser and provider are pre-cisely not equal. It is the customer who gets prece-dence - in return for economic gain; and quite a lotof latitude is allowed to consumers in pursuing anddefending their own interests against providers orsellers. Finally, consumerism is usually unconcernedwith responsibilities of users or consumers to oneanother, and it tends to ignore all but the relationsaffecting economic competition between providers.In the NHS context, however, users have responsi-bilities to one another, and so do competingproviders. Users have responsibilities to other usersnot to overburden the NHS, for example; andproviders have responsibilities not to pursue compe-tition so aggressively that small regional hospitals orvaluable centres of research are wiped out.

Tom Sorell, BA, BPhil, DPhil, is Professor ofPhilosophyat Essex University and Fellow in Ethics at HarvardUniversity,Cambridge, USA.

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76 Morality, consumerism and the internal market in health care

References1 Maynard A. Can competition enhance efficiency in

health care? Lessons from the reform ofthe UK NationalHealth Service. Social Science and Medicine 1994; 39:1433-45.

2 Paton C. Present dangers and future threats: someperverse incentives in the NHS reforms. British MedicalJ7ournal 1995; 310: 1245-8.

3 Royce R. Observations on the NHS internal market: willthe dodo get the last laugh? British Medical3Journal 1995;311: 431-3.

4 The harmony is perhaps only superficial. For criticism ofthis rhetoric see Sorell T, Hendry J. Business ethics.Oxford: Butterworth-Heinemann, 1994: ch 7.

5 Sorell T. The customer is not always right. J7ournal ofBusiness Ethics 1994; 13: 913-8.

News and notes

Teaching research ethicsThe fourth annual workshop on teaching researchethics will be held from June 25-28 this year at IndianaUniversity.

Presentations will include: Shaping scientificthought: ambiguities in the practice of science;Investigating allegations of scientific misconduct;Conflicts of interest in research; Using animal subjects

in research, and Responsible data management.For further information please contact: Kenneth D

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News and notes

Contemporary challenges in health care ethics

The Kennedy Institute of Ethics is offering anintensive course designed to address the mostchallenging topics in health care ethics. Thecourse provides the opportunity for participantsfrom other fields and disciplines to come together fora few days to explore the theoretical framework andpractical issues of bioethics with a distinguishedfaculty.

Course participants receive a one-year membershipto the Kennedy Institute Members' programme;

membership benefits include subscription to theKennedy Institute of Ethics Jrournal and invitation to theannual members' symposium. Continuing medicaleducation credit and continuing education units areavailable for each course.For further information please contact Emily Wilson:

tel: (202) 687-6771; fax: (202) 687-8089.KICOURSE(gunet.georgetown.edu. Kennedy Insti-tute of Ethics, Box 571212, Georgetown University,Washington, DC 20057-1212, USA.

News and notes

Call for papersA conference entitled Values in Psychiatric Nosology: AConference for Philosophers and Mental Health Pro-fessionals will be held from December 4-6, 1997 (tenta-tive), in Dallas, Texas, USA.

Papers are being called for; the submission deadlineis August 1 1997.The University of Texas Southwestern Medical

Center at Dallas, the Cary M Maguire Center forEthics and Public Responsibility at Southern MethodistUniversity, and the Association for the Advancement ofPhilosophy and Psychiatry are sponsoring the confer-ence, supported by a grant from the GreenwallFoundation.The conference aims: (1) to provide an intimate

forum for an exchange of viewpoints about the role of

values in psychiatric classification; (2) to improve thequality of future diagnostic classifications through anenhanced awareness of value issues; and (3) to makeconcrete and specific suggestions to psychiatric nosolo-gists about how value-related nosological problems canbe addressed in future editions of the DSM or ICD. Aselection of the conference papers and discussion willbe published in book form.For further information and manuscript require-

ments contact: Linda Muncy, Administrative Co-ordi-nator, Values and Psychiatric Nosology Conference,Department of Psychiatry, UT Southwestern, 5323Harry Hines Boulevard, Dallas, TX 75235-9070, USA.Telephone: 214 648 3390; facsimile: 214 648 7980;e-mail:<LMUNCY@mednet,swmed.edu>

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