1. Occupational Motivations

It is generally assumed that economic transactions in markets or business are based on self-interest. The seller attempts to obtain the best price the market will stand and the buyer attempts to obtain the lowest price available. An influential statement of this view can be found in a well-known passage in The Wealth of Nations (WN). Adam Smith tells us that it is not from the benevolence of the butcher, the brewer or the baker that we expect our dinner but from their self-love or self-interest.Footnote ¹ This passage is the classic statement of the belief, taken as a given to this day, that self-interest is the motive underlying all market transactions.

The classic statement of the contrasting view that the relationship between doctor and patient is not based on self-interest but is fiduciary or based on trust and benevolence is provided by Smith's contemporary and near neighbour, John Gregory. John Gregory (1724–76) was a cousin of Thomas Reid. He moved from the Chair of Medicine at King's College, Aberdeen, to the Chair of the Practice of Physic in Edinburgh, where he became Physician to the King in Scotland. In 1766 he gave a series of lectures in Edinburgh on the duties and qualifications of a physician. He provides an interesting and surprisingly up-to-date account of the intellectual qualities required by a physician. Having discussed these he goes on to outline the moral qualities which a physician requires. He writes:

Gregory's contribution to the ethics of medicine is summed up by a recent editor of his Lectures:

Just as Smith's views on the self-interested nature of the market have come to dominate economic thinking by the market so have Gregory's views on the benevolent nature of medicine come to dominate ethical thinking in medicine and indeed ‘the professions’ more generally.Footnote ⁴

Consider the following typical quotations:

Or:

The contrast between the position of Smith (and his successors in economics) and that of Gregory (and his successors in medicine) may be summed up as follows: we get our commodities from the self-interest of the market but we get our treatments from the benevolence, altruism and fiduciary nature of the medical profession. In this paper I wish to argue that this contrast is over-stated and that the two occupational categories are much closer than the quotations from Smith and Gregory and their successors suggest. I shall refer to the views of Smith and Gregory, but my arguments are intended to be of contemporary relevance rather than purely expository or critical of Smith or Gregory.

In more detail the contrasts between markets and medicine can be broken down as follows:

I shall examine the contrasts between marketeers and doctors under these general headings, paying attention, but not exclusively, to the views of Smith and Gregory.

2. Interests: customers and patients

An important point to note is that the concept of ‘interest’ is not a clear one. In particular there are two ambiguities which are relevant to my purposes: the term ‘interest’ is used ambiguously to refer both to an end or interest which someone is pursuing and to a motive for pursuing that end or interest; and it can be used both in a psychological or descriptive sense and in a normative sense.

Consider the first ambiguity. We can ask people what their interests are, or what ends they are pursuing; but we can also say of someone that when he/she is pursuing a given end (which may be her own good or that of another person) she acted out of the motive of self-interest.

Consider the second ambiguity. When we are using ‘interest’ in the psychological or descriptive sense we are concerned with what people actually want to have, but in the normative sense we are concerned with what they ought to have, whether or not they in fact want to. We might say that in the former sense we are concerned with what people are interested in and will therefore want to have or to attend to, but the latter sense is concerned with what is in their interests, and therefore with what they might sometimes not want to have or to attend to. The latter normative sense can be used with significance only in contexts where there is an assumption about a person's true nature, or what his/her true good or interest consists in. In the framework of WN (whatever Smith's personal philosophy was) the psychological and the normative senses tend to run together, for a person's true interest in such a framework is simply the satisfaction of his/her wants. This is the ground for one typical moral criticism of the free market economy – that it presupposes or even encourages an impoverished, ‘getting-and-spending’, view of the self. I shall develop this criticism in section 4.

Applying my analysis of the first ambiguity to the cases of the butcher, baker and doctor I can now suggest that the interest of the butcher qua butcher and that of the baker qua baker is not in their own advantages but rather in the dispensing of meat and bread; these are the ends they pursue, their ‘interests’ in that sense. Likewise, the interest of the doctor qua doctor is in the health of his/her patients. That is the aim, end or ‘interest’ of the doctor's skills and activities. This is not a moral point, but simply a definition of these occupational activities. But it will be said that the more important aspect of the first ambiguity concerns the respective motives of marketeers and professionals in pursuing these ends. It will be said that the motives of the marketeers are self-interested as Smith suggests, while the motives of the doctors are benevolent as Gregory suggests. But the position here is more complex than that simple contrast implies.

We can readily admit that Smith's butcher will not (usually) serve a customer out of the motive of benevolence. But will he always serve him out of the motive of self-interest? If we regard this question as an empirical one the answer is uncertain. It is never easy to tell what a person's motives are or, indeed, whether he/she is acting from motives at all as distinct from habit. But it seems implausible as an empirical hypothesis that the actual motives of everyone engaged in market transactions are invariably those of self-interest.

Take first the matter of profits from a market transaction. In cases of one sort a person may enter into a market transaction from altruistic motives, as when he/she sells the goods in order to make a profit for (say) Oxfam. Smith of course was dismissive of the idea of trading for the public good,Footnote ⁷ but he was writing before charities became involved in the market. In another range of cases, a common one, the profits do not go to the person engaging in the transaction but to his/her employer. The seller in these cases may be acting with the sole motive of being good at the job and that is not necessarily the same as self-interest, although sometimes it might be if commission is involved. Again, the seller might have no motive at all but simply be acting out of habit.

Take next the matter of the provision of goods. No doubt many traders put goods on the market with the sole aim of making a profit for themselves, but it is plausible to say that some at least put goods on the market because they see a need for goods of a certain sort and put them on the market with the motive of supplying that need. To take a topical example, a scientist may see a need to develop a system for carbon capture, develop a scheme, and with the help of funding from a science foundation put it on the market to supply that need. It is therefore not obviously true, far less necessarily so, that all commodities are marketed from the (motive of) self-interest. No doubt the super-sleuths of cynicism will try to detect the ‘dear self’ underlying all market transactions. But it may be that other analytic possibilities will enable us to bypass the unhelpful opposition of self-interest and benevolence. If we can avoid these terms it will be possible to help the fly out of the bottle!

One escape route is not to attempt to identify market or medical transactions in terms of motives but to use another category entirely. People engage in market transactions or become doctors and practise medicine for all sorts of motives the investigation of which is a matter for psychology or sociology. It is more helpful philosophically to depict both market and medical transactions as taking place within types of relationship or relation. What is a ‘relation’ or a ‘relationship’?

The term can be used in two main ways: to refer to what I shall call a ‘formal tie’ between people or institutions, and to refer to the attitudes which people or institutions may have towards each other. For example, we might ask, ‘What is the relationship between these two?’ and receive answers such as ‘Father and son’ or ‘Teacher and student’ or ‘Baker and customer’ or ‘Doctor and patient’. These are examples of what I shall call ‘formal ties’. Such ties can be familial, professional, or commercial, and no doubt there are other possible types of formal tie. But I want to stress, as it will be central to my analysis, that to a greater or lesser degree formal ties are legally regulated. The formal ties of kinship are no doubt lightly regulated but the formal ties I am concerned with – the commercial and the medical – are underpinned by complex legal and quasi-legal regulation. Turning to the attitudinal aspect of relationships, we might ask: ‘What is the relationship between these two?’ and receive answers such as: ‘John is very proud of his son, but his son despises him’, or ‘John trusts his doctor, but his doctor's heart sinks when he appears’. These are relationships depicted in terms of attitudes. Attitudes, unlike formal ties, do not have legal underpinning.

Applying this analysis first to an economic relationship we find, as I suggested, that the formal tie will be a juridical one, based on conceptions of justice. Smith in fact devotes his entire Lectures on Jurisprudence (LJ) to the necessary legal and juridical underpinnings of all trades and arts. ‘The first and chief design of every system of government is to maintain justice’.Footnote ⁸ More specifically, an economic order requires an already existing system of rights, in the sense that exchange is always at a ‘price’, and price is an agreed exchange ratio. Moreover, the establishment of an economic relation is ipso facto the establishment of a juridical relation in so far as it constitutes a contract defining the rights and duties of the parties. In other words, a purely economic relation is an abstraction; all economic relations are integrated with juridical relations, and the self-seeking of the parties is thereby limited. Hobbes's man ruthlessly pursuing his self-interest is not in an economic order until the sovereign establishes a legal order. A fuller account of an economic order would need to refer to other facts: the influence of scarcity and of political conditions which allow a measure of freedom of choice. But for present purposes it is sufficient to point out that in an economic transaction there is a formal tie, regulated by complex juridical rules, which will limit the unbridled pursuit of self-interest. If the juridical tie fails in this – as it often does – it is because the rules are not stringent enough, or have not been stringently applied.

Turning more briefly to the formal tie between doctor and patient we can say that it similarly is legally regulated. Whatever else the doctor/patient relationship may be it is formally a juridical one. It is beyond my present brief to record the gradual regulation of the doctor/patient relationship since the time of Gregory. But the relationship has increasingly been governed by juridical and quasi-juridical rules such as those nowadays laid down by the General Medical Council in the UK and similar bodies elsewhere in the world. Among other functions they minimise any exploitation of patient vulnerability. Hence, the doctor is similar to the butcher and baker in that their relationships with customers or patients are alike governed by formal, juridical ties.

What of the attitude component in the two types of relationship? Here we find an interesting difference. Beginning with traders in the market we can ask what kind of attitude do they (as traders) have to their customers?

In this context it is helpful to use a term introduced by the Reverend Philip Wicksteed (1844–1927) – ‘non-tuism’:

‘What makes an economic transaction is that I am not considering you except as a link in the chain, or considering your desires except as a means of gratifying those of someone else – not necessarily myself. The economic relation does not exclude from my mind everyone but me; it potentially includes everyone but you.’Footnote ⁹

or again,

Thus, he concludes:

As we might nowadays say colloquially, the market relation, in terms of the attitudes involved, is one of ‘anyone-except-you-ism!’

A relation of this ‘non-tuistic’ sort is not simply regulative of conduct in the market – it is not just a guiding principle – rather it is a necessary constitutive condition of a market, in the sense that where it does not obtain we do not have a market but some other relationship between people. Markets, then, do not presuppose the operation of self-interest as a motive, but they do presuppose a special sort of relation, in the attitude sense, which, following Wicksteed, I am calling ‘non-tuism’, a non-tuism governed by juridical ties.

If we turn now to the situation which obtains between a doctor and a patient in the attitudinal aspect of the relationship we find that it is the reverse of that which must obtain in the market. In the market the relationship must be one of ‘non-tuism’ – otherwise a market cannot (logically) exist. On the other hand, the doctor must be in a ‘tuistic’ relationship, otherwise he/she cannot treat the patient. The patient's medical interests or benefit must be consciously in the doctor's mind otherwise the medical consultation won't work. Note here however that this point does not give the doctor any moral superiority over the trader in the market. To say that the doctor's interest in the patent is ‘tuistic’, that the doctor is concerned with the medical benefit of the patient rather with her\his own benefit, is not to make a moral point but simply to describe the job of the doctor. In other words, this ‘tuism’ is not the benevolent interest which friends may show in each other; it simply serves to identify the point or ‘interest’ of the job. There are of course benevolent or indeed altruistic doctors. For example, some doctors work in dangerous situations, or work beyond or outside the call of duty, and most will communicate with their patients in a caring manner and show concern for their patients as appropriate. But these are contingent, if highly desirable, ‘add-ons’ to the relationship. The essence of the medical relationship requires only that the intentional object of the doctor's attitude should be a health benefit for the patient. But the intention to confer benefits is not exclusive to the doctor, for all those who work in the division of labour aim to create or confer some kind of benefit through their work, whether it be baking bread or repairing a burst pipe. As Aristotle tells us at the opening of the Nicomachean Ethics, all activities aim at some good – the medical art aims at health, the art of shipbuilding at making a vessel.Footnote ¹² It is simply a confusion to extrapolate from this neutral sense of ‘good’ or ‘benefit’ to a moral sense. If all those who confer benefits on us by means of the division of labour are to be called ‘benevolent’ in the moral sense then the word ‘benevolent’ will be emptied of its suggestion of the morally praiseworthy.

The professional relationship, as has been stressed above, is also regulated in its formal tie by legal and quasi-legal rights and duties. To put it another way, the medical benefit made possible by the attitude of ‘tuism’ is being filtered through a professional role. Current literature on medical ethics is given to stressing that patients are persons. But it is also true that they remain patients; the relationship is a professional one with the rights and duties that are thereby entailed.

3. Profits and Fees

A second contrast sometimes drawn between the market and the professions is that while profits are essential for successful economic activity – indeed are its main point – fees are not the main point of professional activity but are incidental to it. This seems to follow from the respective positions of Smith and Gregory. Smith devotes large sections of WN to different sorts of profit.Footnote ¹³ By contrast, according to Gregory:

The contrast here is misleading however. The contrast between the trader and the professional must be drawn at the same point in the chain of service. The professional is described by Gregory as ‘benevolent’, but, as I have argued, that simply means that a medical benefit is conferred at the point where the service is delivered – during actual patient contact. But that is compatible with saying that professional contracts for services rendered are negotiated at another point in the chain. Whatever was the case in the time of Gregory there is no doubt that medical bodies nowadays negotiate fees in a business-like or non-tuistic way. Equally, a business will negotiate its prices in a non-tuistic way; the astute business man or woman will consider what the market will stand in the form of prices. But that is compatible with saying that at the point of delivery of service a sales person may offer advice to a customer in a tuistic manner by considering what would best fit the requirements of the customer.

It is simply a muddle to contrast the benign service at which the doctor aims with the self-interested profit at which the trader aims. The doctor supplies services in a ‘tuistic’ way – aimed at providing a medical benefit tailored to the patient's needs – but doctors are also fee-earners, and it would be disingenuous to pretend that their professional bodies do not attempt to maximise their fees for professional services and to insist on fees for matters such as the signing of certificates of sickness or indeed passport photographs, and for taking part in drug trials. Equally, business men and women profit from supplying the goods and services necessary for our wellbeing, but it is unfair to suggest that at the point of delivery of service there is no attempt to provide a service fitting to the needs of the customer. Of course, there are rogue and unscrupulous marketeers – this has recently been apparent in the financial sector – but equally there have been unscrupulous profiteering doctors.

Smith himself has views on the remuneration of doctors. He considers why some wages are higher than what he calls the ‘natural’ rate of wage, and offers five reasons: disagreeable, highly skilled, and insecure work make up three reasons. A fourth is the degree of trust required and here he cites jewellers and goldsmiths, and lawyers and doctors. Smith says that the confidence we place in doctors and lawyers ‘could not safely be placed in people of very low condition’.Footnote ¹⁵ He notes also the length and expense of training. His fifth criterion is improbability of success. He mentions lawyers here, but medicine in Gregory's day could also be included. Smith's account of medical fees is more realistic than the idealism of Gregory (and his present-day successors).

4. Wants and Needs

So far I have been comparing the moral qualities of the market and the professions from the points of view respectively of the trader or business person and the doctor. I shall turn now to a comparison of the two from the points of view of the consumer and the patient. Take first an alleged moral weakness of the market as it affects the consumer. As we shall see Smith was aware of this issue, and it involves the second of the ambiguities I noted in the term ‘self-interest’ (section 2) – that between the psychological or descriptive sense, what a person in fact wants to have or is interested in, and the normative sense – what is in a person's interests whether or not he/she in fact desires that thing or state.

Smith argues that self-interest coupled with a natural tendency to ‘truck and barter’Footnote ¹⁶ causes human beings to set up markets, and bargaining power in the market is immensely increased by division of labour. The point of a market so described is fundamentally to order and create the goods which human needs require, but which human beings cannot supply on a simply self-help basis. But critics of the market from Plato on have pointed out that there is an inevitable transition from the attempt to satisfy basic human needs (‘interests’ in the normative sense) to the attempt to satisfy wants and preferences unconnected with needs (‘interests’ in the psychological sense).Footnote ¹⁷ In other words, a market gradually but inevitably creates inordinate desires for its goods, and this is said to be morally corrupting because eventually no one has a conception of his/her self other than in hedonistic terms, as a consumer. While it is shameful, the criticism runs, that some people in some parts of the world cannot get the basics they need it is also unfortunate that in a prosperous free market economy people are encouraged by powerful advertising to want what they do not need. This type of criticism can be levelled at the free market because, as I said earlier, the normative and the psychological senses of both ‘interests’ and the ‘self’ run together to the extent that the good of the self consists simply in the satisfaction of interests in the sense of psychological desires.

Now there is some justification for this kind of criticism. One need not be ascetic to feel some repugnance at the excesses of the free market in a prosperous society. Indeed, as I said above, Smith was himself aware of the dangers of consumer excess. Personally a man of frugal tastes and an admirer of the Stoics, he criticised excessive commodity consumption, using terms such as ‘baubles and trinkets’ which he contrasted with ‘the necessaries of life’.Footnote ¹⁸ As far as he personally was concerned the great merit of the free market was that it enabled the true self-interest of the consumer to be satisfied in the provision of the material necessities of life – ‘the riches of a country does not consist in the quantity of money employed to circulate commerce, but in the great abundance of the necessaries of life’.Footnote ¹⁹ Nevertheless, he did not anticipate the extent to which the consumer can be corrupted and exploited by sophisticated modern advertising.

Turning more briefly to the consumer side to medicine we might at first be tempted to think that there could be nothing corrupting in patients' desires for health. This is obviously true if we think of health as simply the absence of disease or illness, as the medical equivalent of ‘the necessaries of life’. But medical science has progressed enormously since the time of Gregory, and can now offer not only cosmetic surgery but drugs which can make patients feel ‘better than well’.Footnote ²⁰ Moreover, the hyperbole associated with screening programmes, for example, makes whole sections of the community vulnerable to fears that are based on uncertainties, and creates desires for the services which medicine claims to offer. If the market developed from Smith can be criticised for corrupting our sense of self with ‘trinkets of frivolous utility’ the medicine developed since the time of Gregory can equally be criticised for tempting us to improve on our basic human nature.

5. Competition and Collegiality

Smith stressed that a free market economy required competition. To this end he argued that governments should repeal old laws no longer applicable, should abolish the privileges of corporations with respect to apprenticeships, and above all should abolish monopolies. All these improve the regulation of the formal ties in the market. Of course, a competitive free market, as outlined by Smith, has been criticised (and praised) on the grounds that it allows minimal scope for governmental intervention. Smith's well-known view was that individual self-interest would activate the ‘invisible hand’ for the benefit of all.Footnote ²¹ He did of course allow that the government should finance large public works such as bridges,Footnote ²² and he also thought that governments should impose basic education.Footnote ²³ But since the time of Smith governments have debated how far the competitive nature of the free market should be limited by State intervention. I shall not venture into this well-known economic battle-ground but simply observe that some measure of competition is a necessary condition of a free market, and is basic to the views of Smith.

Does this stress on competition mark a difference between Smith and Gregory or the market and medicine? It is worth noting that in the time of Gregory the physician did face a measure of competition, from apothecaries. In 1704 the Society of Apothecaries won a case in the House of Lords (known as the ‘Rose Case’) against the Royal College of Physicians. The ruling allowed apothecaries both to prescribe and to dispense medicines.Footnote ²⁴ But as the 19^th and 20^th centuries progressed the right to medical practice was increasingly confined to licensed medical practitioners. Whereas this can be defended by stressing the need to protect the public by ensuring that only properly qualified doctors may practice, cynics might argue that doctors have succeeded in establishing a monopoly.

Governments in the UK and elsewhere have recently tried to introduce a measure of competition by means of the doctrine of patient choice – concerning hospital, doctor and increasingly concerning treatment. This policy raises three questions. Firstly, there is the question of whether genuine consumer choice concerning doctor, hospital and treatment is consistent with a publicly funded health service in which some degree of equity must morally govern scarce provision. A full discussion of this question is beyond the scope of this paper. Secondly, there is the question of whether competition can successfully be introduced into a profession in which the training stresses collegiality. This is a matter for psychologists. Thirdly, we might ask whether the doctrine of patient choice (a necessary condition of competition in the health sector) is consistent with what is said to be the fiduciary nature of the medical profession. A discussion of this issue is relevant to the issues of this paper.

6. Choice and Trust

As I pointed out in section 1 medicine regards itself as a ‘fiduciary’ profession, or one based on trust. This was certainly the view of Gregory himself:

But in tension with the view that medicine is fiduciary there has been the rise of the doctrine that patients should be involved in treatment decisions affecting them. This doctrine began in the 1950s simply as a stress on patient consent to treatment, but it has developed through the idea of joint (patient/doctor) decision-making into what is now largely a consumerist approach to medical practice. Governments in the West have encouraged this shift in public attitudes, on the grounds (perhaps mistaken) that this will improve standards. Now, in order to make a free choice of goods or services in the market, consumers require only to be given accurate information on their purchases and the possibility of redress if things go wrong; they do not need to trust the seller. In other words, consumerist assumptions differ from fiduciary ones. This changed culture has come about because the success of the free market which has developed from Smith has encouraged governments in the west to extend market assumptions to other areas of public life, including medicine. This extension constitutes a serious threat to the fiduciary nature of medicine as understood by Gregory and his present-day descendants.

It might of course be argued that whereas there can be informed free choice in the market, medicine must remain fiduciary because the flow of information can never be adequate or be adequately understood for genuine choice – we know what kind of apples we want but are less confident over information on chemotherapy, or on assessing operation success rates. But while this is true its truth has limited application. As far as medicine goes it is true that I may not understand the statistical probabilities of success in some areas and may therefore be obliged to trust my doctor, but in other areas I may be well-informed from the internet and have no need to take my doctor's assurances on trust. This situation, however, is exactly paralleled in the market. Perhaps I can make informed choices on apples, but if my car mechanic tells me that I need an engine transplant I am in no position to dispute, unless I am technically trained. And most of us must trust our financial advisers with their actuarial complexities on matters such as pensions. In fact, many areas of the market will work only if there is an element of trust, which means that much of the market operates on fiduciary assumptions. The importance of trust to the effective operation of the market is evidenced by the heavy penalties imposed by regulators when betrayal of trust is discovered, as recently in the banking sector. Hence, the practice of medicine in the contemporary world and the operation of the market are alike at least to the extent that each requires both informed choice and a degree of mutual trust. Medicine and the professions more generally do not have a monopoly of the fiduciary.