A challenge on autonomy in care?

I came across a fantastic article, that, at least for me, could be a game changer. It deals with clinical practice in the Amish communities of America. The Amish faith dictates they vet very carefully any innovation for stuff that could introduce perverse incentives in their lives. They prize something they call “autonomy”: electricity, for example, can be bad if it powers activities that will make people drift away from the community, but it’s OK for, say, lighting your workplace. What’s not OK is the electric grid, which means now the community is coupled to the broader world in a way the Amish find troubling. This is why the Amish have solar panels.

Autonomy in health care has a number of very interesting implications.


Here are some highlights (but do yourselves a favour and read the whole thing).

  • The Amish refuse to have insurance. "When someone gets sick, the church collects alms to help the patient cover expenses."
  • This might happen at a time when the community has other objectives as well ("setting up a farm for a young couple"). You can ask of the community to support your treatment, but its costs are not simply discharged into an anonymous "system": they are borne by your own brothers and sisters. As a result, everyone focuses on not spending more money than is necessary, and "[Amish] communities are highly interested in health education and disease prevention".
  • For this reason, the Amish use genetic screening of children. Prevention is so important that its benefits trump the disadvantages of dealing with the world at large.
  • They develop their own treatments (one for burns is described in the article). They navigate, with some difficulties, the interface with the mainstream medical world: clinical testing etc. These treatments tend to be very cheap. 
  • Communities negotiate discounts, which hospitals are willing to offer in exchange for payment in full at the time of service. In one example (a child treated with surgery for colon cancer) price was negotiated down to 19,000 USD from 172,000, a 90% discount. "For Americans with health insurance, it may come as a surprise that hospital costs are negotiable". 
  • The Amish don't sue. "When the Amish told [a doctor] they understand doctors are human and make mistakes, he had to pause to let that sink in. To them, he was not simply a member of the medical establishment, but an autonomous individual doing his best, given the choices and information before him." 

All of which plays well into @Lakomaa’s and @Tino_Sanandaji’s institutional model of health care.

I propose we roll out a challenge on autonomy and responsibility. What are people doing to be less dependant on state- and private sector provided health care? Are they helping each other? Is there prevention going on? Dietary tips circulating, sports clubs to help people stay motivated to work out? Yoga, meditation? I believe there are massive links there. It’s quite likely that the returns on prevention are quite high!

@Nadia ?

@Noemi ?

@markomanka ?



I think this is very cool and meshes well with some of the conversations Jeremie Zimmerman and I have been having about care for individuals and groups who may not want or be able to use public or private sector provision of services.

Don’t sue

When I studied medical engineering the professor told this (madeup or actual?) story:

Mathematicians make 0.03%  errors,

Engineers 3% errors,

Doctors 30% errors.

That’s an understanding of conditions of medical science that our system/society tend to fail. Medicine is very non-deterministic.

And as posted we need to handle this question up front

Collect alms to cover expenses

Does this not induce a time lag before the patient is actually treated?

One would expect to have a economic ‘buffer’. (money could be collected to cover next future case).

What if it’s an unwanted individual that no one likes and will support?

@Alberto how can this business model be used for a OpenCare clinic?