Member Essay
Protecting the Medical Commons—
Ensuring Adequate Care
By Dale J. Block, MD, CPE
In this article…
U. S. health care has become a tragedy like the commons
of old where herdsman added too many sheep to
sustain and the commons became overgrazed.
Garrett Hardin, in a landmark article The Tragedy of
the Commons, 1 published in the journal, Science, described a
class of human problems that had no technical solutions.
He stated, “A technical solution may be defined as
one that requires a change only in the techniques of the
natural sciences, demanding little or nothing in the way of
change in human values or ideas of morality.” Hardin was
discussing the issues related to population growth. Hardin
develops a scenario that remains appropriate for discussing
health care stewardship and population health management
in the 21st century:
The tragedy of the commons develops in this way.
Picture a pasture open to all. It is to be expected that each
herdsman will try to keep as many cattle as possible on the
commons. Such an arrangement may work reasonably satisfactorily for centuries because tribal wars, poaching, and
disease keep the numbers of both man and beast well below
the carrying capacity of the land.
Finally, however, comes the day of reckoning, that
is, the day when the long-desired goal of social stability
becomes a reality. At this point, the inherent logic of the
commons remorselessly generates tragedy.
As a rational being, each herdsman seeks to maximize
his gain. Explicitly or implicitly, more or less consciously, he
asks, "What is the utility to me of adding one more animal
to my herd?"
This utility has one negative and one positive
component:
1. The positive component is a function of the increment of
one animal. Since the herdsman receives all the proceeds
from the sale of the additional animal, the positive utility
is nearly + 1.
2. The negative component is a function of the additional
overgrazing created by one more animal. Since, however,
the effects of overgrazing are shared by all the herdsmen,
the negative utility for any particular decision making
herdsman is only a fraction of - 1.
Adding together the component partial utilities, the
rational herdsman concludes that the only sensible course
for him to pursue is to add another animal to his herd. And
another…and another.
But this is the conclusion reached by each and every
rational herdsman sharing a commons. Therein lies the tragedy. Each man is locked into a system that compels him to
increase his herd without limit—in a world that is limited.
Ruin is the destination toward which all men rush, each
pursuing his own best interest in a society that believes in
the freedom of the commons. Freedom in a commons brings
ruin to all.
In 1975, the delivery of health care and resource utilization was in the forefront of America’s medical establishment. Dr. H. H. Hiatt, a prominent health care futurist of
the times, uses Hardin’s story on “The Commons” as the
backdrop for his landmark essay, Protecting the Medical
Commons: Who is Responsible?, published in the New
England Journal of Medicine on the precarious availability of
resources available for medical care. 2
Hiatt states that, “The total resources available for
medical care can be viewed as analogous to the grazing area
on Hardin’s commons, and the practices drawing on those
resources compared to Hardin’s grazing animals.”
Hiatt notes that no one would argue that there is a limit
to resources any society can devote to medical care and that in
