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Ann Thorac Surg 2000;70:351-353
© 2000 The Society of Thoracic Surgeons
a Distinguished Professor, Tufts University, Boston, Massachusetts, USA
Address reprint requests to Dr Kassirer, 150 Hickory Rd, Weston, MA 02493
The delivery and the cost of health care are once again the focus of great public attention. The defeat of the Clinton health-care plan in the 1990s initiated the fastest and most sweeping changes ever in our health care system. Although the plan was conceived in idealism with an intention of providing universal coverage, it went nowhere, in large part because of the political ineptitude of our national leaders and the lobbying efforts of the insurance industry. In the process, government has essentially been eliminated as the prime mover in the organization of health care in favor of a massive experiment in which private health-care markets now deliver and manage care. Many involved in this conversion simply consider health care a marketable commodity.
The changes in health care delivery over a few short years have been remarkable. The familiar model of one-on-one patient-physician care in solo practice has been replaced by large physician groups, massive integrated systems, and huge for-profit hospital and insurance conglomerates. Numerous new stakeholders have emerged, including health care lawyers, consultants, advertising agencies, and for-profit entities.
Those who tout the benefits of the market takeover of medicine fail to point out that in medicine, the market is far from perfect and that this conversion has led to many untoward consequences. A major manifestation of market failure is the growth in the number of uninsured and underinsured people in the United States, now representing more than 44 million Americans. Medical education is threatened. Academic medical centers, which have been under siege financially for years, are facing serious deficits. Some of these centers have already made deals with the for-profit sector to bail themselves out of massive debts, and some have even gone bankrupt. Vertical integration, a strategy that was never based on empirical observations, has faltered, as have several medical center mergers. Some of the best health management organizations are losing money, and some are in receivership.
Doctors are not much better off. They are overwhelmed by paperwork and administrative requirements, feel rushed because they have to see too many patients, and have lost autonomy in making many decisions regarding patient care. Physicians are worried about declining incomes. Some are taking jobs in consulting or management, getting retrained, or retiring early, and some are joining unions. Our professionalism is also injured. Some doctors have compromised their principles and are selling vitamins, alternative medicine potions, and Tupperware in their offices. Others are falling prey to a variety of financial conflicts of interest.
There is extraordinary pressure on the integrity of practicing doctors. As the rate of growth of funds for patient care slows, physicians are tempted to protect their incomes. As care becomes more tightly managed and as more physicians are expected to pay attention to the overall health and expenses of a panel of patients, the temptation to undertest and undertreat is substantial. In this setting, financial conflicts of interest arise that pit the ethical behavior of a physician toward his or her patients against that physician’s personal finances. The incentive for doctors to preserve their jobs may be so strong that they may no longer act exclusively as the patient’s advocate. People simply cannot tolerate being put in this position, and that stress can produce an even greater threat, namely, the loss of integrity. Eventually, some physicians will conform to the restrictions and deceive themselves into thinking that they are doing their best for the patient when, in fact, they are providing suboptimal care.
The times have changed in many ways. Our ethical standards, which have evolved over the past 2,000 years, never envisioned a market-driven health-care system. We also never imagined that as individual physicians, we would be responsible for the care of a defined population of patients rather than only 1 patient at a time. We live in a period in which the temptations are stronger than ever to break the ethical rules, particularly those involving financial conflicts of interest, and we now encounter a certain permissiveness that not only gives a quiet nod to relaxing these rules, but encourages entrepreneurialism. Money seems far more important to doctors than ever before. Moreover, the group has become the mode of practice. Like it or not, it is here to stay, and we must develop new rules that protect and preserve professionalism in this new environment.
Given these fundamental changes, to preserve our profession we have to reaffirm the fundamental covenantal relationship that must exist between a physician and his or her patient. The best description of this relationship, in my opinion, was given by Cardinal Joseph Bernadin, in a speech to the AMA House of Delegates in December 1995, shortly before he died of pancreatic cancer. He said
The covenant is grounded in the moral obligations that arise from the nature of the doctor-patient relationship. They are moral obligations—as opposed to legal or contractual obligations—because they are based on fundamental human concepts of right and wrong. While ... it is not currently fashionable to think of medicine in terms of morality, morality is, in fact, the core of the doctor-patient relationship and the foundation of the medical profession. Why do I insist on a moral model as opposed to the economic and contractual models now in vogue? Allow me to describe four key aspects of medicine that give it a moral status and establish a covenantal relationship: First, the reliance of the patient on the doctor. Illness compels a patient to place his or her fate in the hands of a doctor. A patient relies, not only on the technical competence of a doctor, but also on his or her moral compass, on the doctor’s committment to put the interests of the patient first. Second, the holistic character of medical decisions. A physician is a scientist and a clinician, but as a doctor is and must be more. A doctor is and must be a caretaker of the patient’s person, integrating medical realities into the whole of the patient’s life. A patient looks to his or her doctor as a professional adviser, a guide through some of life’s most difficult journeys. Third, the social investment in medicine. The power of modern medicine—of each and every doctor—is the result of centuries of science, clinical trials, and public and private investments. Above all, medical science has succeeded because of the faith of people in medicine and in doctors. This faith creates a social debt and is the basis of medicine’s call—its vocation—to serve the common good. Fourth, the personal commitments of doctors. The relationship with a patient creates an immediate, personal, nontransferable fiduciary responsibility to protect that patient’s best interests. Regardless of markets, government programs, or network managers, patients depend on doctors for a personal commitment and for advocacy through an increasingly complex and impersonal system. This moral center of the doctor-patient relationship is the very essence of being a doctor. It also defines the outlines of the covenant that exists between physicians and their patients, their profession, and their society. The covenant is a promise that the profession makes—a solemn promise—that it is and will remain true to its moral center. In individual terms, the covenant is the basis on which patients trust their doctors. In social terms, the covenant is the grounds for the public’s continued respect and reliance on the profession of medicine.
Many recall longingly the "golden age" of medicine several decades ago. However, some of it was fool’s gold, with its unchecked fee-for-service payment system, its rampant inflation, and its individualism as a fundamental principle for the approach to everyday medical practice. The public has had enough with differences in practice style, with emotionalism instead of evidence as a basis for medical decisions, and with medical errors that go unreported and unfixed.
Where does managed care fit? It certainly has become the major mode of practice and has taken the lion’s share of the beating by the public and the press. Much of the criticism is well founded and well deserved. Nevertheless, health plans are not all the same. The older plans, most of which were not designed primarily for profit, have worked well in general, but they have proved hard to sustain financially. A number of the plans that raised the ire of the public were begun by insurers, many without experience in health. In the past, these plans often excluded the sickest patients, rationed by inconvenience, and denied care by a variety of mechanisms.
However, it is too easy to make managed care the demon. In fact, managed care has forced us to pay more attention to cohesion of care, long-term management of chronic diseases, measurement of the quality of care, satisfaction of patients, prevention of unnecessary hospitalizations, investment in information systems, and cost-effectiveness of our medical interventions. I believe that we would never have made such rapid progress in these areas without the pressure from managed care.
Nonetheless, if we accept the premise that health care has a special moral status, then it follows that, as in many countries, there should be universal access to necessary care in the United States. We should argue that it is unacceptable for people to suffer or die because they cannot afford insurance and that it is unacceptable for people to become bankrupt to pay for a serious illness. We should be unwilling to accept these consequences of market failure.
As a practical matter, what can we do as individuals? How can we preserve our integrity and the covenant between ourselves and our patients in the new environment? Here are some thoughts. First, we must declare that we are concerned foremost with the preservation of health and the care of the sick and that we will continue to base our clinical judgments on our evolving body of highly specialized, scientifically based knowledge, not on personal expediency or political motives. Second, we must declare that we have intentionally set our ideals and ethical standards high, and that these ethical standards lead us to act in ways that are not self-serving.
Third, we must be far more responsible for the use of resources than we have been in the past. We should pay attention to the cost of care even when it does not come out of our wallets. We should learn the techniques of disease management and practice them if they both improve care and cost less. We should use less expensive drugs when they are just as good. We should take the time to discuss choices with patients and families when aggressive care is not the only option. We should stop overtreating patients in our intensive care units to preserve a few more days of life of questionable quality.
Fourth, we must be sure that our own house is in order. Financial inducements are all around us. We should not be fooled into thinking that we cannot be influenced by the largesse of pharmaceutical companies and device manufacturers. Getting co-opted by industry is increasingly frequent and can have a pernicious influence on even the most senior clinicians and investigators.
Fifth, more individuals must get involved in both practical and ethical issues in local and national associations. We need more volunteers to join the well-intentioned and ethical organizations that are trying to make a difference, but they must be principled people who will avoid the herd mentality. We need individuals who are willing to put in the time, rise to the top, and make their views heard. It is the only way to avoid the kinds of embarrassments, scandals, and gross mistakes that have occurred in state and national medical societies over the past few years.
Sixth, despite the recent National Labor Relations Board ruling, we should not be seduced into joining unions. Unions are designed to deal with the economic and social problems of their members, not professional issues. Some of our national medical organizations already behave like unions, and when they do, their opinions and policies are often discounted.
Seventh, we must always be agents for beneficence. We must speak out against profiteering by the burgeoning medical industry and argue vociferously for continued support for teaching and research.
In the past, professionalism involved individual and personal choices. In fact, it still does, but for better or worse, most physicians are now part of an organization. As a consequence, we need to begin to think about how we as individuals can make contributions to the group and how we can ensure that there are contributions to patient care by the group. To preserve our moral compass, we must develop a new philosophic underpinning for those physicians whose principal professional activities are virtually exclusively in groups. In fact, given the group structure, there may be no better way in the current system to be our patients’ advocates than to act through the group.
I offer these practical approaches. We must open our professional practices to scrutiny. We must overcome our ignoble history of inadequately dealing with doctors who we knew were substandard practitioners or alcoholics. We should no longer tolerate having no regular reporting of the quality of our work. We can do this if we develop an honest and open peer-review system and if we participate in the review of others and have others assess our own practices. Anyone taking a new position should ask: how will my practice be assessed, how will I participate, and how will I learn from it? Nobody likes cookbook medicine, but we have been guilty of failing to implement many tried and true methods for which there is compelling evidence. In this sphere, our new professional responsibilities are to better understand basic concepts of quality, to participate in the hard work of evaluating and updating these standards, to obtain the necessary leadership skills to implement these practices, and to make sure that our organization gives us sufficient professional time to carry out these tasks. We must try to shift some of that responsibility to our groups. We can insist on becoming familiar with the group’s budget for free care and how decisions to provide care are made. We can try to influence the amount of free care whenever planning is underway.
In short, we can continue to make contributions to the quality of care overall, to the care of the poor, and to the maintenance of the trust of the public. We can continue to try our best to keep people healthy and to heal the sick. Practicing medicine in the community or working in a medical center is still a privilege. Doctors still make a decent living doing work that benefits people.
Having expressed this view, however, I have a final cautionary note. As members of our profession, we alone must be its keepers. We must continue to be vigilant in case the consequences of a market-driven delivery system go too far and prevent us from giving the kind of care we believe to be appropriate. As guardians of the profession, we must decide when we have crossed the line between appropriate care and assembly line care, when our prearranged schedule of seeing an office patient every 8 minutes precludes us from giving patients the personal attention they need, and when sending them home from the hospital too soon compromises their care. We must be willing to try to change the system when it is seriously malfunctioning.
It is up to each of us. The solutions to the troublesome ethical and moral conundrums in medicine today are not scientific facts just waiting to be discovered. Rather, the answers are within us, and though these dilemmas are among the most difficult issues we face, it is our task to come to grips with them. As we do so, it will be a test of the will and resolve of each of us to be responsible, accountable, ethical, and humane in the complex and still evolving medical world of the 21st century.
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