I wanted to return to that idea of Merck (and the other drug companies) settling into a role as a "regulated public utility." You can find calls for that sort of thing (in Marcia Angell's writings, for example), and there seem to be people who find the whole idea really appealing.

Me, I find it disgusting. And I don't even know which part of the idea I find most revolting. Is it the thought of working for a pharmaceutical version of the Post Office, with what would surely be a dynamic risk-taking culture? Is it the thought of waiting. . .waiting. . .while higher and higher bureaucratic commissions and review boards grind slowly on to tell us what we should work on next?

Or is it just that the idea is so unworkable that I feel pity for a person who advocates it? Look, electricity and water are utilities. Rail service can be treated as one (and doesn't Amtrak do a fine job at it?) But these are mature industries whose task is to deliver steady amounts of known goods. The drug industry doesn't fit any of those criteria.

We argue about what diseases to treat, and how to attack them. We argue about which drugs to try, and how to use them. We disagree about the best ways to start finding the drugs in the first place. We don't even understand many of our therapeutic targets that well, and there are many others that we haven't even heard of yet. Different populations need our products in completely different ways at different times, and vary widely in their ability (not to mention their willingness) to pay for them. Does this sound like a good candidate for public utility theory?

Only if you imagine a big machine, grinding away and producing grey blocks of something called "Health Care." It all reminds me of what someone said about Woodrow Wilson, that he had the most abstract mind the speaker had ever encountered. A normal person might watch a train go by and see a train, he said. Wilson, though, saw Transportation.