A man – let's call him Joseph K. – is slicing up a cucumber when he suddenly cuts off the tip of his thumb. He hastens to the E.R., where a doctor clips off the finger of a plastic glove, pours antibiotic into it, slips it over the thumb, then wraps a bandage around the entire finger.
That night the pain is so excruciating that Joseph – who wasn't given a painkiller – can't sleep. In the morning he phones the E.R. The woman who answers denies that he has reached the E.R. He hangs up, re-checks the number, and calls back. She then admits that it is the E.R., but insists that he has called “a strange number.” The ensuing conversation establishes that it is not, in fact, “a strange number,” but that the E.R. is simply not open at this hour. Until 3:30 P.M., the E.R. operates out of another location in the small, relatively remote town in which Joseph resides. “Call there,” she says dismissively.
Joseph does so, and is told that there's no more room on their schedule for the day. “But you're an E.R.!” he says.
“Well,” comes the indifferent reply, “you can come over and take a number.” But the chances of getting to see a doctor before closing time, he is warned, are slim.
He decides to give that option a pass. Some time later he phones the first place again, and gets the same woman he talked to earlier. “Oh, you again!” she groans.
He tells her that his thumb is still in great pain. “I think the doctor wrapped it too tightly,” he says. “I'm coming over there later, when you open.”
“You can't just come here!” she snaps. “This is for acute cases, and that's not acute! You've been going around with that finger all day!”
“Yes, but if I'm in a lot of pain, you can't refuse to let me come to the E.R.!”
“Well, make an appointment if you insist, but you should know – there's not always a doctor here!”
“What? There's not always a doctor at the E.R.?”
“Yes, there's not always a doctor here!”
“OK, well, can I ask you something? The bandage is so tight. Can I clip part of it off?”
“I can't answer that. A doctor has to decide.”
“But what if there's no doctor there?”
In the end he decides not to go to the E.R. after all. The next day, after another twenty-four hours of intense pain, he removes the bandage to find that a gigantic blister, the result of a too-tight bandage, has engulfed his entire thumb.
No, this isn't a story from Uzbekistan or some such place. This episode, which took place last week, is just the most recent (and probably the most innocuous) item in my ever-expanding collection of anecdotes about encounters between people close to me and the health-care system in Norway. You know, the country that is constantly being named by the UN and a host of other organizations that presume to quantify such things as the world's all-around most super-duper and wonderfulest place to live (most recently, just the other day, by Britain's Legatus Institute); the country whose health-care system Michael Moore chose not to cover in his film Sicko because, he claimed, it was so terrific that nobody would believe it.
Before I proceed, another story, this one from three years ago. The protagonist this time is Joseph K.'s brother, Judah, who got a splinter of metal in his eye while working on a car and went to the same E.R. visited by Joseph in the anecdote above. The doctor on duty asked Judah if he would be paying with cash or a credit card. When Judah said that he didn't have either form of payment on him at the moment, the doctor spat out: “Then go home and go blind!”
Yes, he said that. It's not made up, folks, outrageous though it is. It's just an example of the sort of thing that can happen – and that you really can't do a damn thing about – when you socialize a health-care system.
I don't mean to suggest that the American health-care system is without blemish. Far from it. By some measures, it's been going downhill for a long time. My late father, an internist in New York, went to medical school in the 1940s and to the end of his life, like many doctors of his generation, thought of medicine as a ministry, a calling. He was always ready to answer the knock on the door in the middle of the night and run off with his medical bag to the house of some neighbor he didn't even know – often staying there till morning, not only treating the patient but trying to put the family at ease. There was, of course, never any talk of payment. In his later years, he ranted more and more about the boom in malpractice suits (and malpractice insurance), the preoccupation of all too many of his younger colleagues with profits rather than patients, the ballooning cost of health care (partly owing to a growing reliance on expensive, unnecessary tests rather than on diagnostic skills), and the advent of HMOs. He felt that the precious relationship between physician and patient was being replaced by something increasingly cold, businesslike, and drained of personal concern and trust.
In his view – and he was right – this system needed an overhaul. But he was equally insistent that the answer didn't lie in the kind of socialized medicine offered in countries like Norway. He didn't live to hear the word Obamacare, but he wouldn't have liked the idea.
I'll admit this: if, like me, you're a self-employed person with a marginal income, the Norwegian system is, in many ways, a boon – as long as you're careful not to get anything much more serious than a cold or flu. Doctors' visits are cheap; hospitalization is free. But you get what you pay for. There are excellent doctors in Norway – but there are also mediocrities and outright incompetents who in the U.S. would have been stripped of their licenses long ago. The fact is that while the ubiquity of frivolous malpractice lawsuits in the U.S. has been a disgrace, the inability of Norwegians to sue doctors or hospitals even in the most egregious of circumstances is even more of a disgrace. Physicians who in the U.S. would be dragged into court are, under the Norwegian system, reported to a local board consisting of their own colleagues – who are also, not infrequently, their longtime friends. (The government health system's own website puts it this way: if you suspect malpractice, you have the right to “ask the Norwegian Board of Health Supervision in your county to evaluate” your claims.) As a result, doctors who should be forcibly retired, if not incarcerated, end up with a slap on the wrist. When patients are awarded financial damages, the sums – paid by the state, not the doctor – are insultingly small.
Take the case of Peter Franks, whose doctor sent him home twice despite a tennis-ball-sized lump in his chest that was oozing blood and pus – and that turned out to be a cancer that was diagnosed too late to save his life. Apropos of Franks's case, a jurist who specializes in patients' rights lamented that the Norwegian health-care system responds to sky-high malpractice figures “with a shrug,” and the dying Franks himself pronounced last year that “the responsibility for malpractice has been pulverized in Norway,” saying that “if I could have sued the doctor, I would have. Other doctors would have read about the lawsuit in the newspaper. Then they would have taken greater care to avoid making such a mistake themselves. But doctors in Norway don't have to take responsibility for their mistakes. The state does it.” After a three-year legal struggle, Franks was awarded 2.7 million kroner by the Norwegian government – about half a million dollars.
Another aspect of Norway's guild-like health-care system is that although the country suffers from a severe deficit of doctors, nurses, and midwives, the medical establishment makes it next to impossible for highly qualified foreign members of these professions to get certified to practice in Norway. The daughter of a friend of mine got a nursing degree at the University of North Dakota in 2009 but, as reported last Friday by NRK, is working in Seattle because the Norwegian authorities in charge of these matters – who have refused to be interviewed on this subject by NRK – have stubbornly denied her a license. Why? My guess is that the answer has a lot to do with three things: competence, competition, and control. If there were a surplus of doctors and nurses instead of a shortage, the good ones would drive out the bad. Plainly, such a situation must be avoided at all costs – including the cost of human lives.
Then there's the waiting lists. At the beginning of 2012, over 281,000 patients in Norway, out of a population of five million, were awaiting treatment for some medical problem or other. Bureaucratic absurdities run rampant, as exemplified by this Aftenposten story from earlier this year:
Helga Kvinge discovered a lump in her breast in February. She couldn't get an appointment for a check-up at Oslo University Hospital before April 3. So she contacted a private hospital and was examined there.
On March 1, she got an appointment at the private center that offers to check whether women have cancer. A few days later she was informed that the lump was cancer. The tests were sent to the laboratory at Oslo University Hospital Ullevål, and the doctor who made the diagnosis works at both OUS and the private hospital.
Kvinge, and the doctor at the private hospital, were sure that since it was clear she had cancer, she would receive an offer for treatment at Oslo University Hospital since she lives in Oslo.
But on Thursday of this week she was informed by OUS that she couldn't be treated for her breast cancer until OUS itself had made the diagnosis.
Then there's the Oslo-area couple whose one-year-old daughter fell and broke her arm. They took her to a nearby hospital, where over a period of hours they signed in, were sent to a waiting room, saw a doctor, and had X-rays taken – only to be told that the little girl couldn't get a cast put on her arm there because the family's address put her in another hospital's district. They went to the other hospital, where they were put through the whole rigmarole all over again. Not a tragedy, but an example of the kind of dehumanization that infests the entire system.
And let's not forget rationing. “Death panels” are no fantasy. In a series of articles in 2010, Aftenposten reported on the decision by the Norwegian government's health director to refuse certain treatments to certain “large patient groups” in order to curb costs. For example, “we can extend the lives of patients with heart failure by installing a heart pump...but this is a service we probably can't offer. It's too expensive.” The same goes for respirators in cases of emphysema or chronic bronchitis: “It could prolong the lives of patients, but it's not something we can give to such a large group.” The elderly, likewise, are screwed: “we...spend too much money to extend the last phase of life for dying, often old, people.” Who's to decide who receives treatment and who doesn't? That, the health director answered, is a “political responsibility” – the job of politicians, not physicians.
I can't imagine how my father would have reacted if he'd heard a doctor, especially one in a position of authority, say such a thing. For my father, having the letters M.D. after his name represented a sacred trust. He saw it as his responsibility to do everything in his power to heal – period. To even speak of putting a price tag on a human life was the height of obscenity.
But that was long ago, and in another country.
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