「医療に市場原理」???
「医療に市場原理を導入することによって、医療の無駄をなくすべき!」
という議論があります。そういった意見に対して思うことがあります。
市場原理は無駄を省く、というのは、論理の通っていない思い込みに過ぎません。
資本主義、と呼ばれる大量生産大量消費主義の社会では、市場はミクロのレベル
(会社、商品、サービス等の現場)では無駄を削る方向に動きますが、マクロの
レベル(社会、環境等の全体)では「無駄」によって成長するものだからです。
資本主義が社会主義になぜ勝つことができたのかを考えればわかりやすいのでは
ないでしょうか。
前者が後者に勝てたその理由は、「無駄」「欲望」の二つがキーワードだと思い
ます。
後者は、「欲望」を制限し「無駄」を省こうとした。計画経済、などが代表です。
それは、マクロの無駄を省こうとする作業。でもそれは、市場の活力を殺し、ミ
クロの無駄を多量に産生した。
前者は、「欲望」を制限せずそれを活力として利用し、生存とは無関係な「無駄」
のままに社会を動かした。だから、余力が生まれ、遊びが生まれ、社会に活気が
でき、いろいろなものが生み出された。そして社会の内部は豊かになった。
(たとえば、今年の色はこれ!とか書いているファッション雑誌とか、無駄・欲
望をつくり消費をつくることで経済を回転させ活性化させる)
「欲望」がkeyになるというのは株価の上昇などみていると、わかりやすいです。
ひとの「欲望」を刺激したものが価値を高める。欲望と実質は別に離れていても
いい。ちょっと前のITバブルのように。
また資本主義で生き残るためにはミクロのレベルで無駄を省かないといけない。
そうしないと、他者に勝てない。無駄を省いてがんばる存在だけが生き残る。そ
れもまた社会を「効率化」させ活性化させる。
でも、マクロのレベルで無駄ができる。貧しい国ほど金持ちは大金持ちで、貧乏
人は極貧であることからもわかるように、そのマクロな無駄は国を貧しくします。
社会主義とは逆なわけです。
(まあ、ソ連・中国などは党という組織で階級を再生産してマクロな無駄をつく
り国を貧しくしていましたけれど…)
日本は国民皆保険という「社会主義」でコントロールされてきました。だから、
ミクロのレベルでは無駄は多かったり満足度は低めたりしたけれども、マクロの
レベルでは無駄が少なかった。それが、世界的にみて医療費が非常に低くもレベ
ルの高い現状をつくりました。でもやっぱり、現場の満足度はどうしても低く…。
それも社会主義の側面。
そしてより質の高い医療を、という欲望に手綱を握らせた「資本主義」で医療を
推し進めたのが、アメリカ医療。派手で質の高い成果はほんとうにたくさんあり
ます。「欲望」に基づいて「遊び」をつくること(弱者を切捨てたり、医療従事
者という資源がより少ない途上国から医療従事者を吸い上げたり、など)が正当
化され、さらに派手で質の高い医療をつくり、さらに遊びを大きくし、さらに質
の高い医療をつくる…
でも今、さすがに「遊び」もつくれなくなりパンクしているアメリカがいます。
付け加えるならば、資本主義にすることで得をする人々がいるから、「市場原理
の導入!」が声高に叫ばれるわけです。得をするひとがいるということは、損を
するひとがいるということ。質量保存の法則は、真理。そして、市場原理の導入
によって、ミクロの無駄がへり、マクロの無駄がふえ資源を吸い取られそこで得
をするひとができたとき、ミクロのレベルの資源が減り犠牲となるのは現場に関
わるひとびと、つまり患者であり医療従事者。
市場原理によるミクロのレベルの無駄削減は想像しやすくまた目に見えやすいけ
れど、それは無駄をマクロでつくる選択です。弱者を切り捨てたり、より弱者か
ら資源を吸い上げたり…。
アメリカの保険会社の例も、見過ごせません。アメリカでは医療現場に何も関わっ
ていない何も生産していない保険会社の従業員が大量に存在し、それが医療現場
で患者と医療者が血を吐きながら生み出した成果を吸い上げています。
隣の水は甘いと信じてしまうのが人の性ですけれど、勤勉な日本人は、社会主義
医療国の今の方針を、現場の満足度を高めるように追求し続けるほうが幸福だと、
ぼくは思うのですけれど…
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