The quest for autonomy should be medicine’s ethical basis. A person afflicted with pain or debilitating illness can do little else but attend to the demands of their malady. Offer that person some relief, and they can better fulfill their potential. Whenever medical interventions achieve that goal, it is a clear win. All too often though, that’s the start of trouble, because winning is seductive, and it easily displaces less dramatic goals. Casinos could not survive otherwise. And when it comes to healthcare, we’re really in a sort of magic casino.
Players come in the door with a stake, but there are no bets and the only game is Blackjack. Rather than betting, we simply get to keep playing until the house wins and then we have to leave. Meanwhile, there’s the best cash bar ever, Cuban cigars – whatever floats your boat. And there’s more. Interventions are available for purchase. A player can buy the game down from eight decks to one. He or she can spend a little more for the privilege of referring to a strategy chart during play. A little more buys a consultant to count cards for the player. Cards are even for sale. Between the dealer’s hits the house will give or take back a card for a price. All of these changes in the game are analogous to medical interventions in real life, from preventive care to emergency surgery.
The catch is, you can’t win. Sooner or later, the house hits 21 and you have to go. The trick is, remembering that you can’t win and playing to stick around and enjoy the bar and the Cuban cigars while you can. Ignoring your cards doesn’t make sense, but neither does hunching over the table with your card-counter whispering urgently in your ear.
Of course, the house could try to help the players out. It could require the purchase of a single deck game on entry. It could hire a concierge to tap players on the shoulder when they forget what they’re about and start to play to win.
Right now, the house of medicine is satisfied with being an honest shopkeeper. It is loath to get involved with purchase decisions because it mistakenly views those choices as, categorically, an expression of autonomy when they are not. They can lead to an increase in autonomy, but they can lead to an ultimate loss of autonomy as well. Too many players are fixated on their hands in eight deck games, trying desperately to win, a card counter at their side and no cigar money left. Surely, we could do better.