Virginia Postrel's book, The Future and Its Enemies, is about the forces that create the future. The author makes some interesting points and brings unique insights that may be of interest to physicians who are attempting to understand and influence the changes occurring in our health care delivery system. However, the book has some flaws, including the author's seeming acceptance of corporate socialized medicine as the product of a normal free market.

Postrel's book is logically organized into eight chapters with an excellent introduction. It is easy to read and she uses many interesting examples to make her points. The first chapter, "The One Best Way," starts out discussing a TV debate on Crossfire between a conservative and a liberal. In the debate, both of them agree on the need to control future technological changes. She uses this right/left agreement as a springboard for her major thesis that conservatives and liberals are both stasists because they both resist change. She says stasists come in two types; the reactionaries who want to preserve the status quo and the technocrats who want to control change. She says that most political debates revolve around the reactionaries who try to preserve the status quo and the technocrats who have different competing regulatory plans.

The second chapter, "The Party of Life," discusses dynamists. These people create the future by inventing and bringing new goods and services to the marketplace. Subsequent chapters as "The Infinite Series" and "The Tree of Knowledge" give informative discussions about how innovations and change builds upon each other. Each new invention creates almost infinite new ways that the world can be put together. Subsequent chapters show how stasists' attempts to control the future do little more than create problems. She contrasts the autocratic government rule making of the stasists with the trial and error methods of the dynamists.

Postrel implies that the dynamists and stasists are separate people. I would question this. For instance, I recently had lunch with a doctor-inventor who lamented the five years it took the Food and Drug Administration to approve his medical device. I asked his opinion about having the FDA regulate only safety or even abolishing the FDA. He responded that this was much too radical but he did believe in streamlining the regulatory process. He did not question technocratic control over his invention. In other words, people can be dynamists in their individual endeavors while at the same time they can be technocrats in the collective.

Postrel postulates that dynamists and stasists are the major forces trying to shape the future. This is an interesting insight, but I question this.

Conservatives, liberals, and radicals are also important forces that mold the future. Liberals try to use the government to obtain social change for what they consider the better. To this end, they advocate a single-payer health care system. They also resist individual control by resisting medical savings accounts. Conservatives represent businesses as physicians. Many of them lobby the government for medical savings accounts. Other businesses as insurance companies see this as a loss of business and lobby to retain the status quo of managed care.

On page 213, Postrel says: "By contrast, dynamist forbearance patiently lets trial-and-error evolution take its course. It certainly does not demand an end to criticism --- managed care is far better when patients raise a ruckus about unresponsive bureaucracy --- but neither does it insist on immediate, official, top-down, once and for all action."

With this statement, Postrel's dynamist-stasist approach seems to fall apart. She believes that without government interference, the dynamists will solve our health care problems by using their trial and error methods. This is naive. She ignores the notion that bad laws beget more bad laws. In other words, past government interference in the marketplace may have caused the dominance of managed care. If so, individual dynamism of trial and error will not change the bad law. Only the radical change of reversing the law will do this.

In conclusion, with Postrel's dynamist-stasist axis she examines the forces of change in a unique way. The criticism is that the liberal-conservative-radical axis cannot be so easily dismissed. They also try to mold the future. For physicians interested in molding the future, I recommend this book because it is insightful and thought provoking. By her using the U.S. health care system as an example, it gives physicians a chance to think through her premise that government change is not needed to reverse the dominance of managed care.

Reviewed by Bert Loftman, MD
Atlanta, GA

Dr. Loftman is a neurosurgeon and 5th District Director of Americans for Fair Taxation. E-mail: b.loftman@gte.net.

Originally published in the November/December 1999 issue of the Medical Sentinel. Copyright©1999 Association of American Physicians and Surgeons.

(The Future and Its Enemies by Virginia Postrel. The Free Press, New York, 1998, 253 pp., $25.00, ISBN: 0-684-82760-3.)