In 1968, Garrett Hardin, an ecologist and professor, wrote a seminal article entitled "The Tragedy of the Commons.” He argues that if a resource is held in common for use by all, then ultimately that resource will be destroyed. Hardin states, "freedom in a common brings ruin to all." To avoid the ultimate destruction, we must change our human values and ideas of morality.
The metaphor he uses in this original article is a "common" – the grassy field at the center of a village in medieval Europe that was shared as a common resource by farmers with grazing cattle. Eventually, as each farmer pursued his logical and predictable goal, the resource was destroyed.
A more striking and local example is the famous Boston Common, pictured at right in a 19th Century sketch, which was originally used as a common property by farmers to graze their cattle until overgrazing destroyed it and the common was closed to all grazing. When he first wrote about the tragedy of the commons, Hardin pointed out that there is no possible technical solution to this problem. The only solution is a change in values.
Herschel Elliot, a professor of Agricultural and Biological Engineering at the University of Pennsylvania, expanded this thinking with the following: “The general statement of the tragedy of the commons demonstrates that an a priori ethics constructed on human-centered, moral principles and a definition of equal justice cannot prevent and indeed always supports growth in population and consumption. Such growth, though not inevitable, is a constant threat. If continual growth should ever occur, it eventually causes the breakdown of the ecosystems which support civilization. ... Specifically, Hardin's thought experiment with an imaginary commons demonstrates the futility -- the absurdity -- of much traditional ethical thinking.”
So what is the lesson for health care? We are in the same boat. Health care is a resource held in common for use by all, and we are overgrazing it. In an editorial in NEJM, the three ‘farmers’ grazing the health care commons are providers, patients, and insurers.
What is the solution? Hardin says "mutual coercion mutually agreed upon." There are numerous historic examples though many of us would find them hard to accept. Hawaiian islanders developed a severe yet effective set of rules for managing their scarce (and visibly) limited resources. Either you followed the rules for maintaining the resources or you were subject to the death penalty.
What is the health care parallel? Those who study this problem suggest two solutions: restricting access and creating incentives to invest in the resource rather than exploiting them. That is a huge challenge for those of us in health care. Restricting access to expensive end-of-life care is unappealing to us, yet critical to providing resources to those who need preventive care. Shifting payment to rewarding value over volume does achieve investing in the resource rather than exploiting it.
We are on the right road and the discipline to focus on value (at the expense of our individual self interest) will be extremely challenging. As Hardin predicted, this change in values is the only answer.
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