The Axis of Evil


My recent post about Medicare allowing patients to use drug vouchers was met by a rousing reception.

By crickets.

It seems that some saw me as one who (gasp) trusted the pharmaceutical companies to do something good.  Has Dr. Rob lost (what\’s left of) his mind??  Drug companies do everything with themselves in mind, and there are always strings attached.  They can\’t be trusted.  They are evil.  Doesn\’t Dr. Rob realize that?

I have heard the same thing about insurance companies.  I had a patient a few days ago use the word evil when describing the insurance industry.  I myself have called them rabid wolves, have decried the outlandish CEO salaries,  and have declared that they do a whole lot of things that hurt patients and make my life difficult.

The third member of the axis of evil is the government – specifically our dear congress that can act in such a decisive way.  They are playing chicken with the future of physicians and patients; they are under the influence of the money of lobbyists; they are frequently more focused on party dominance and reelection than they are serving those who voted for them.

Clearly our problems would be solved if we could only rid ourselves of these evildoers.  Clearly the moral fiber of those leading the pharmaceutical and insurance industries are suspect at best.  Come on, simply being included on the same list as the members of congress is witness to our opinion of their morality, right?

No, actually.

OK, now it seems obvious that Dr. Rob has either gotten into some funny mushrooms or is accepting cash payments by the above mentioned evildoers.  How could anyone look at what these people do to our system, what they take out of that system and put in their own bank accounts, and not call them evil?

I don\’t disagree that many things that come out of each of these groups is very destructive to Americans.  But consider what task each of these groups performs:

  • Pharma – To design and sell drugs that treat or cure diseases.
  • Insurance companies – To remove the immediate impact of the high cost of healthcare and make it more manageable for people requiring care.
  • Congress – To make laws and design systems for the best interests of the citizens of our country.

All of these tasks are not only not bad, they are actually necessary.  We would be worse off without them.  So if the underlying tasks of these industries are not what make these groups do things that harm us, then what goes wrong?  It must be the people, right?

No, actually.

I do agree that there are people in each group making decisions that help themselves and harm others, but I don\’t think they are unique.  Human nature drives us to self-preservation and self-promotion at the expense of others.  Perhaps it\’s survival of the fittest, or perhaps it\’s original sin, but the reality is that people everywhere act this way.  We are deluded to expect that people with an open opportunity to profit at the expense of others would always shun that opportunity.

Read history, folks.

It is far too easy to hide behind moral condemnation.  The folks on the right side of the political stadium are famous for portraying the left as evildoers, but the people on the Left are just as quick to condemn CEO\’s, religious leaders, and talk-radio personalities as being evil.  We all like to look down on others as evildoers, seeing the replacement of these scoundrels with someone moral (like us) as the cure for any woes our system faces.  Doing so is not only simplistic, it nearly eliminates any chance of working together on things, and it gives them license to call us evil when we get our chance in power.

As a doctor, I am one of the targets of the evil label.  How could we doctors become rich off of others pain?  How could we have our enormous salaries when our system is going down.  Clearly we need doctors who are morally upright.  Hearing such accusations makes me want to lash back.  I see what good I do in my situation and see how others stand in the way of my doing more good.  I want to jump up and down, point, and scream at the axis of evil as being the root of the problem, not me!  And what would these groups do in return?  They vilify us greedy doctors.

I will admit that I am very set on maintaining my present lifestyle and bettering it if at all possible.  That\’s pretty normal, isn\’t it?  True, I have resisted the temptation to choose a more lucrative specialty; I don\’t whiz 40 patients through my office each day; and I don\’t do procedures in my office to make extra money off of my patients.  Yes, those are moral choices for me. But these choices get harder each year with the ratcheting down of reimbursement and the growing hostility toward doctors.  It\’s tempting to say, \”Screw them, I am just going to take care of myself and open a boutique medicine clinic.  I can have no pressure, more time with patients, no insurance headaches, and a much nicer lifestyle.\”  Many have made this choice, and I personally don\’t blame them.  They aren\’t evil either.


The problem is not the morality of the people in the system, it\’s the system itself.  Pharma has been given the ability to set exorbitant prices, maintain patents for very long periods of time, and even gouge once medicines become generic.  The system has been set up to encourage this, and they are simply doing what they are allowed to do.  Insurance companies are under huge pressures for quarterly profits by their shareholders, and so are required to milk the maximum dollar from the system.  They are allowed to do this as well.  Congressmen and women are allowed to make a career out of being a politician, are not really accountable for the money they accept from special interest, and have all sorts of other rules to make it hard to stand on principle.  We have set up our system that way.

I don\’t think it\’s wrong to condemn the practices of these groups, nor do I think doctors shouldn\’t be revealed for any unethical practices.  The world is better when people play nicely.  But we need to hop off of our pulpits, put down our torches, and put away the scarlet letters that conveniently put the blame on others.  This is not the problem of others, it is our problem.  We are the ones with the power to change these things.

There is one catch: we must work with those evildoers over there to get anything meaningful done.

9 thoughts on “The Axis of Evil”

  1. Dr.Rob, I agree with what you have said. I have long thought that human nature was the problem. I've wondered why the powerful don't care about a more compassionate and safe world for their grandchildren to live in. I even went through a period of being very upset at what humans do that I don't approve of. I now think that people will act like people just like chimps will act like chimps. I think the people of the USA have gone too far down this road of greed and violence. I hate how difficult the world will be for my grandchildren.

  2. I still think we need to fight it, but vilifying people is the wrong way to do that. We need systems that actually take human nature into account.

  3. Well said. “Systems that actually take human nature into account.” Exactly!

  4. Dr.Rob–great post. Although white collar psychopaths do exist and are certainly also part of the problem in these organizations of great power, they probably comprise a small but influential percentage of the players. Simple human nature combined with systems that have rules that easily permit people to take advantage probably explains most of the “evil” behavior you refer to.

  5. I've always felt the Z Axis is pretty evil. Of course the point of origin can be a little difficult too.

  6. Such a sensible post, as usual.

    I worked in Managed Care for many years. Most of us were decent people who truly cared about our members. The ones who didn't and were caricatures of Evil? The ones in between us in senior management and the truly clueless at the very, very top.

    I believe in well run Managed Care. It makes a difference in people's lives FOR THE BETTER. I have a chronic illness whose treatment costs thousands of dollars a month. I pay co-pays of less than $100.

    When I wrote a harmless, benign little article for Kevin Pho's website suggesting ways to work with Managed Care until something better came along, I was so vilified I thanked God they didn't know where I lived. It didn't help that Dr. Kevin, who I otherwise adore, changed my title from “The Dichotomy of Managed Care” to something along the lines of “Managed Care: Deal With It”. lol

    When I worked at HealthNet, one man, whose wife was denied a dangerous experimental treatment, told me he wished me and my children dead. My children! Dead!!!

    All of this partisan, rage filled nonsense needs to stop and it boils down to exactly what you said: we have the power to change things, we cannot choose apathy and we all must work together.

    Ah, Dr. Rob, when you and I are running the world, things will be a LOT different. 🙂

  7. Usually the problem is the wrong incentives, I think. Here is a great article…. As you can see September 2009 Atlantic

    I hope this worked, I had a late night

    … I hope this isn't fatigue driven ranting ……
    Sometimes the problem is “evil” or more correctly responding more to the financial pressures than I think is appropriate.

    What frightens, really frightens me is when its stupidity. Medical directors are often smart, but they can't and don't know everything. Some realize this, many do not. PBM managers , who I deal with a lot seem to be pretty ill-informed, I suppose I seem the same to them . I have many tales of epic stupidity–not evil, just cluelessness . The employee at the insurance company who denies insulin for a type 1 diabetic who “used too much this month” on the Thursday before Memorial day( this happened in 20o9) doesn't realize the patient will be ill, and hospitalized by Tuesday morning or if he/she was for some reason unable to get fluid and insulin might even die. . The clerk is not evil, perhaps not even stupid, just ill-informed. Thank God for the drug reps who baled the patient out with “gateway” samples, driving an hour each way to deliver them on that Friday morning . I have also had anti-rejection drugs denied .

    I am also troubled by laziness. SOrry to pick on phramacy, that's a big contributor to my late night. It infuriates me when I do a PAR which they CLEARLY do not read . I do about 7 or 8 per week , my assistant 2 or 3 times that many . Mine are usually for high cost drugs (Forteo, Namenda, oral Vanco, Symlin) which are not first line . I send a letter with the items that pertain highlighted in bold. They deny it . I appeal .I know I am using this drug correctly, because like Dr. Rob I am CHEAP. They deny, I send the letter and their form which has now arrived (we contract with > 100 plans), they deny again and then either this round or next, we are on to the conference call. I have never been denied after the conference call, 100% of the time someone reads the letter and says , “You don't need to attend, your patient meets the criteria, and we wish you had sent this before”. At this point, I usually point out the date on the letter, magnanimous in victory. There is moment of silence on the other end “I don't know how this could have happened” . I have practiced and I say “its not the first time this has happened, think how much time and money you could have saved if it hadn't had to go this far” . Are these companies evil? No, the PBM staff was just not very diligent, and didn't read the letter or the form. What I don't get is why they don't read the darn forms . That is just laziness, not “trying to deny life-saving treatment”, not necessarily trying to wear us out as part of their financial plan, (although I often suspect that's some of it), its just plain old laziness.

    Human nature- we all want to get home some time today, we all think we know more than we do, and in my case I want to beat the companies at their own game.

  8. Ah, yes, thank you for such an insightful article! In Sondheim's great musical Into the Woods, there's a song sung by the Witch called “The Last Midnight.” I think you might be interested in these lyrics (a personal favorite of mine):

    “Nothing we can do / Not exactly true …
    No, of course, what really matters is the blame. / Somebody to blame.”

    Appropriately, the song that precedes this number is titled “Your fault.”

  9. Agree 100%. I don't think, however, this is evil. Is it lazy? Yes. Is it stupid? At times, yes. Is it selfish? Often. But evil is something beyond. Evil is someone intentionally trying to do bad to others. What you describe is pitiful. A system deals with lazy, stupid, selfish, and pitiful. It doesn't however, deal with evil. Evil is personal, whereas our system is impersonal.

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