Paternalism (and EXTRA “……of
the Year”)


Leonard Zwelling

         It’s way too simple but it does ring true. Republicans are
like your father; Democrats like your mother. Republicans tell you to man up;
Democrats will care for you. Republicans fancy themselves rugged individualists
and self-made men (what happened to self-made women or is this an Adam and Eve
throw back as Eve wasn’t “self-made” but from Adam’s rib? Wait a minute, Adam
wasn’t self-made either). Democrats want to hold hands, eat brown rice and sing
Kumbayah. Republicans are for individualism (this means flagrant and unbridled
capitalism); Democrats for communitarianism (this means some form of
socialism). Of course, these stereotypes are not universally true, but they
aren’t all wrong either.

         The one place this Daddy-Mommy distinction never was made
was in American academic medicine. There it’s “you eat what you kill”. The Golden
Rule is “he who has the gold makes the rules”. Academic medicine used to be a
singular endeavor characterized by intense, individual competition among small
businessmen known as lab chiefs and service directors. It was a meritocracy. It
was Adam Smith at his finest and the product was often the best in the world.
The top heavy, Herr Professor systems of Europe and Far East academia had no
place in America where some of the best and the brightest were the youngest and
least experienced who took brilliant ideas and wove them into scientific gold.

         No longer.

         The great arbiter of the process in the United States was
the NIH and its grant system. This was a free wheeling competition for taxpayers’
funds to pursue one’s research ideas. Success bred success, as it should. Individuals
could use the system to develop their ideas all the way to Sweden and many did.

         But the leveler is broken. The NIH system is tapped out and
can no longer sustain a critical mass of scientists so that academic
institutions could defer having to evaluate their own faculty and rate them. In
the past, all promotion and tenure committees needed to do was look at the
publication list and grant funding of an applicant and know whether academic
reward (promotion and/or tenure) was warranted. Lots of prestigious papers and
grant money—thumbs up. Not so much—thumbs down. But with the journals
publishing more papers than ever that get retracted due to non-reproducible
data and the NIH budget barely staying steady, the burden to pick winners and
losers has shifted to some degree to those at the home institutions of those doing research that will be funded
from sources within the walls of academe or from private philanthropy where
peer-review plays no role.

         In this new world, he who has the gold may or may not be he
with the best ideas but rather he with the greatest political skills who has
assembled the most power. Now who gets funded depends on the favor curried with
a centralized power like a President, Provost or Dean, rather than an NIH study
section of peers. Instead of competing for funds using the best ideas, a more
paternalistic approach to research funding obtains. If your ideas resonate with
those of the father figure boss and moneylender, you get to keep going. If not,
you’re out.

         The one piece of ObamaCare that most infuriates the right,
is its paternalism. Rather than allow people to choose how to cover their
health care needs, it forces Americans to have insurance the specifics of which
are determined by the government because the government knows what’s good for
you—I guess more than you do. Most Americans are not fond of being treated like
children. At the same time, as they become more and more dependent on
“benefits” and “entitlements”, they become more childlike. You don’t believe
me? Try to suggest means testing of Medicare. Good luck with that one as a millionaire
senior in Florida flies into a tantrum.

         And who is more paternalistic, the government that dictates
the specifics of your health insurance benefits or the company for whom you
work that wants certain benefits left out for religious reasons (think Hobby
Lobby). If health insurance is being provided by your company or your
government, don’t be surprised if the benefits may or may not resonate with
what you think is good for you or your family. See:

Americans are schizophrenically plowing forward claiming to resent paternalism
from the government while becoming more and more dependent on the federal
largesse. The health care insurance problem could have been handled a host of
different ways from the generation of high deductible policies plus health
savings accounts (Republican philosophy) to a single payer system based on
taxes and need (Democratic philosophy). Instead, we have the ACA making us eat
our broccoli and then locking the door to the vegetable market when doesn’t work.

         Similarly, investigators are going to become more dependent
on non-competitive sources of funding as the NIH budget is less and less able
to sustain the American infrastructure for basic and clinical research. Perhaps
we can generate some additional money in the NIH competitive pool for research.
Close the intramural program in Bethesda. Sell the land to developers. Move the
administrative infrastructure for external funding to Omaha where the rent is
cheaper and no one has to fly more than 3 to 4 hours to study section.

         Then, let no single individual control all of the research
funding at any NCI-designated cancer center without extensive peer-review of
all proposed research. Even his (or her) own.

EXTRA: “…of the Year”

         Every year at this time, we get the lists—the best of the
year.  Movies, books, blogs, and people.

         Today, Time Magazine named the new Pope person of the year
and that seems about right to me.  Edward
Snowden came in second and that good should triumph over evil at least once this
year is appropriate.

         Sports Illustrated should name its person of the year soon
and I suspect that will be David Ortiz, not only for leading the Red Sox to the
World Series Championship, but the city of Boston back from the marathon

         In that spirit, I want to weigh in with the Knuckleheads of
the Year Award. This is one I invented. I know, I know, there are so many
candidates from Miley Cyrus to the Mayor of Toronto and the Mayor of San Diego
to, but for me, this one isn’t even close. My award for the
Knuckleheads of the Year goes to the American Board of Obstetrics and
Gynecology who once again, in this morning’s NY Times were reported to be coming
between its members and people (men in this case) needing their help.  I can’t make this stuff up.  Enjoy.  

Leonard Zwelling