Senate Majority Leader Bill Frist has launched www​.med​ical​mat​ters​.org, a medical website and blog, as a special project of his PAC. Maybe MedicalMatters should partner with YouTube and give readers a chance to send in home video of themselves so they could be diagnosed by Dr. Frist.

The judge who threw out Maryland’s Wal-Mart law (which would have required large employers to dedicate at least 8 percent of its Maryland employee compensation to health care benefits) apparently did so on interstate commerce grounds:

In yesterday’s decision, Judge J. Frederick Motz of Federal District Court ruled that the Maryland law, which was overwhelmingly passed by the Democrat-controlled state legislature in January, was pre-empted by the federal Employee Retirement Income Security Act, or Erisa.

The act sets out a national standard for company benefit plans, replacing what would otherwise be a patchwork of state regulations.

The law “violates Erisa’s fundamental purpose of permitting multistate employers to maintain nationwide health and welfare plans, providing uniform nationwide benefits and permitting uniform national administration,” he wrote in the decision.

Maybe that same judge should throw out state health insurance mandates. They have the effect of making it impossible for private health insurance companies to engage in interstate commerce. Once upon a time, the right to engage in interstate commerce free of state regulation was something in the Constitution — it did not merely depend on Erisa.

Yesterday, a federal district court threw out a Maryland law requiring Wal-Mart to dedicate at least 8 percent of its employee compensation in that state to health care for its Maryland workers. The law was backed chiefly by the AFL-CIO, which has been attempting to get similar laws passed in 33 other states. Those efforts are now likely dead.

This will, no doubt, come as a disappointment to the National Education Association (NEA), which has had an anti-Wal-Mart campaign since last summer. “Huh,” you say? “What does Wal-Mart have to do with public education?” Well, all those NEA officials have to occupy themselves somehow during slow nights at the casino, or while riding around Hawaii in limousines.

Can pharmacists have a conscience? Activists are demanding that Congress and state legislatures pass laws forcing pharmacists and other health workers to act against their own conscience in such matters as abortion, morning-after pills, and gay parenting.

Some doctors say it violates their conscience to perform abortions or provide artificial insemination for unmarried or gay people. Some pharmacists believe that the morning-after pill is a form of abortion, and their religious commitment forbids them to dispense it.

And now some patients and activists are demanding laws to force health professionals to dispense the care the patients want, no matter how it violates the health worker’s conscience. Activists who march for a woman’s right to choose want the government to overrule a pharmacist’s right to choose.

I was reminded of Arnold Kling’s question “Is Bioethics an Oxymoron?” when I read in the Washington Post the comments of official bioethicist R. Alta Charo: “As soon as you become a licensed professional, you take on certain obligations to act like a professional, which means your patients come first.” As I wrote in an online debate for Legal Affairs magazine,

this is an example of how one state intervention generates the demand for additional interventions. We say you can’t be a pharmacist unless you get a state license, and now you want to say that that license should empower the state to impose morally offensive obligations on those who were required to get the license.

Similarly, we require a prescription to get many drugs, including some forms of contraception. Why should a woman need a prescription for contraception? Why not just grant access to contraception by allowing it to be sold over the counter? Here we’ve created one intervention—the requirement that people get a prescription from a licensed doctor, which they must take to a licensed pharmacist—and it has led to a situation you don’t like, in which some tiny number of pharmacists are refusing to dispense a particular prescription. So you say we should have another rule, another regulation, another intervention.

As philosopher Loren Lomasky of the University of Virginia puts it in the Post article, “Freedom of conscience has been central to our political notions since even before the United States existed. People should not be forced into doing things that they find morally odious.”

Do the people who want doctors and pharmacists to be forced to provide abortions and morning-after pills want anesthesiologists to be forced to participate in executions? I’d bet not. These activists want their moral values enforced by law, they don’t want a neutral rule that all doctors must obey the laws of the state. If they did take such a consistent position, of course, I’d still disagree: anesthesiologists shouldn’t be forced to participate in what they may regard as murder, any more than gynecologists should.

This seems like such a clear issue to me. Yet most of the people in the Post’s online chat about the issue were insistent that health workers must be forced to do as they’re told, regardless of their own conscience. Whatever happened to the liberal claims of individual autonomy, of the right of conscience, of the individual exercising his or her own mind? Gone with the wind, it seems, when liberals have the power to impose their values on other people’s consciences.

In a country of 290 million people and 14 million businesses, we should let these issues sort themselves out in the marketplace. Chances are that major drugstore chains like CVS and Walgreen’s are going to insist that their stores fill all prescriptions. If they have more than one pharmacist on duty at a time, then they may be willing to tolerate pharmacists who avoid filling certain prescriptions. If they do insist that all pharmacists be prepared to fill any prescription presented by a customer, then pharmacists who can’t accept such rules will have to look for jobs elsewhere. And if customers encounter a pharmacy that won’t give them what they want, then they will have to find another pharmacy.

A prime reason for freedom is pluralism. In the modern world we don’t all share the same moral and religious perspectives. The fact of moral diversity is a good reason for toleration and allowing people to sort themselves out in society according to their own moral choices. Freedom in a pluralistic society should mean that individuals get to make their own choices. Sometimes other people aren’t willing to do what we want them to do. But frankly, it’s involuntary servitude to force other people to work for us when they prefer not to. And it’s appalling that 141 years after the Thirteenth Amendment, some people still want to hold others to involuntary servitude.

Much of the justification for an individual health insurance mandate, like that pushed by Massachusetts Governor Mitt Romney and the Heritage Foundation, is that people who lack insurance in the current system still receive medical treatment when needed. The cost of treating these “free riders” is shifted to the insured and the taxpayer. In particular, it is suggested that these uninsured individuals will end up at hospital emergency rooms. Advocates of universal single-payer systems often make similar arguments.

But a new study in Health Affairs shows that that there is no significant difference in emergency room use between insured and uninsured populations. The study concludes that increases in the number of uninsured are not likely to lead to an increase in emergency room visits. However, the study does show that Medicaid beneficiaries use emergency rooms more than either the insured or the uninsured. This may result both from the difficulty that Medicaid patients have in finding primary-care physicians willing to treat them at Medicaid’s low reimbursement rates, and from the fact that emergency room visits are essentially free for the Medicaid patient.

One other finding is worth noting as well. Contrary to public perception, noncitizen immigrants actually use emergency rooms less than citizens. Emergency rooms are not being overrun by illegal immigrants.

In a response to my defense of health savings accounts, Dr. Hébert makes a thoughtful case for the value added by primary care physicians. One way that PCPs add value is through “watchful waiting”:

It used to be that observation was one of the mainstays of medicine. Now everything is scanned, biopsied, and aggressively worked up because specialists find it easier to bill for expensive procedures than for recurring office visits. This shift away from observation towards aggression runs the risk of hurting patients, and is one of the casualties of the microspecialist system.

The (over-) use of such “premium medicine” is one of the main themes of Crisis of Abundance, a new book by Cato adjunct scholar Arnold Kling. As an illustration, Kling writes about a blogger named Quixote who received intensive treatment for her swollen eye:

My guess is that 30 years ago, a patient with similar symptoms would have been treated “empirically,” a term doctors use to describe a situation for which they do not have a precise diagnosis and treatment, so that instead they must use guesswork. A layman’s synonym for treated empirically would be “trial and error.” In this case, the patient might have been sent home with an antibiotic and perhaps a prescription for Prednisone, a steroid used to reduce inflammation. There would have been nothing else to do. In 1975, computerized medical imaging technology was new and exotic, with limited applications.

In contrast, in 2005, over the course of a few days Quixote was given a computed tomography (CT) scan, referred to a specialist, sent to a different hospital, referred to a specialty clinic, seen by a battery of specialists there, and given yet another CT scan. Ultimately, however, she was sent home, as she might have been 30 years ago, with an antibiotic, Prednisone, and no firm diagnosis.

Compared with 30 years ago, Quixote received more services, in the form of specialist consultations and high-tech diagnostics. However, the ultimate treatment and outcome were no different. This does not mean that medicine is no better today than it was a generation ago. The CT scans and specialist consultations could have turned out differently. They might have been critically important, depending on her actual condition. Under some circumstances, treating Quixote empirically with an antibiotic and Prednisone could have been a mistake, perhaps costing some or all of her sight in one eye.

Such is modern medicine in the United States. Doctors are able to take extra precautions. They can use more specialized knowledge and better technology to try to pin down the diagnosis. They can perform tests to rule out improbable but dangerous conditions. But only in a minority of cases does the outcome deviate from what would have been the case 30 years ago.

That’s from chapter one. The remaining chapters wrestle with the question of when we should make use of premium medicine.

(The Cato Institute will host a book forum for Crisis of Abundance from 12–2pm at Cato on Tuesday, August 29. Kling will present, and the Washington Post’s Sebastian Mallaby and NYU’s Jason Furman will comment on the book. Keep watching www​.cato​.org for more details.)

I recently attended a conference at Cambridge University, mainly involving Brits, none of whom had a good word to say about the National Health Service. What a change from times past, when so many British people thought it a matter of national pride to boast that “We have the finest health care system in the world.” (When I lived in the UK, I used to ask such people to what world they were referring, ’cause it sure wasn’t this one.)

Lo and behold, the NHS just released data on “hidden waits,” the time spent waiting for diagnostic tests. As the BBC noted in its coverage:

The figures, for 15 of the most common diagnostic tests including scans, internal examinations and hearing tests, mean that for many patients the wait for diagnosis is as long as the wait for treatment.

If you’re going to get sick with anything serious, be sure to do it in the United States. Even with all the problems facing American medicine and the irrationalities of our financing system, at least you’re likely to find out how sick you are and start treatment before it’s too late.