The physician should be contemptuous of money, interested in his work,
self-controlled, and just. Once he is possessed of these basic virtues,
he will have all others at his command as well.
Can the Medical Profession Survive Flexible Ethics?*
The medical writers of antiquity wrote and discussed ethics merely as individuals trying to find out the best way and the right way to conduct themselves using immutable, self-evident principles and propositions in their dual functions as philosophers and medical practitioners. Ethical principles are absolute, and, in a benevolent profession, reflect the authentic feelings of the members of the profession who have answered a calling and are willing to clearly demonstrate what is right and what is wrong, not echo what is politically expedient, or merely repeat the rhetoric of leaders seeking self-aggrandizement and the fulfillment of their aspirations in organized medicine. These aspirations once fulfilled by many AMA officers are seen less as public service and dedication to the profession than as extravagant living, expedient politicking, and excessive luxuriant travel given the recently cited reimbursement figures paid to AMA officers for 1996 as published in Physician's Weekly.(1)
Physicians are increasingly becoming demoralized with what is happening to their profession and with good cause. I believe the survival of the profession and the professional survival of physicians as members of a beneficent but independent profession, will depend on our ability to articulate eloquently to the public the fact that we have been and remain our patients' best advocates. If physicians are not successful in conveying this message --- and the fact is that with the advent of managed care ethics, we are perceived as having relinquished that responsibility --- the medical profession will become an enslaved government trade union rather than remaining an independent and honorable profession.(2)
Point of fact is the gradual implementation of rationing and deterioration in the level of medical care that is already in place in managed care and HMOs --- and the public is no longer oblivious to these iniquities in medical care. They are finding out that managed care works when they are well but not when they are sick. And that doctors are paid more to deliver less care to their patients. In their new role, physicians are induced to restrict their patients' choice of, and access to, specialists and specialized, high-tech and expensive treatments that are potentially life-saving --- under the pretext of controlling medical care cost. Thus, collective cost considerations have superseded the basic ideals of quality of care and the individually-based sanctity of the patient-doctor relationship, formerly based on trust rather than cost consideration. And for the first time in the history of American medicine, physicians are allowing themselves to be placed in the uncomfortable dilemma of putting the interest of a health care entity (HMO, PPO, etc.), or "society," or the "collective good," above that of their own individual patients and the previously sacrosanct patient-doctor relationship.(3)
Today, physicians are facing a professional identity crisis: Will they lead or will they follow? Many are quitting the profession. Alas, it's obvious that, except for the AAPS, doctors are following, falling in line with the economic requisite and impositions of managed care and HMOs and sadly, doing little to stop this juggernaut. I can understand many physicians have been forced to join managed care merely to feed their families. Yet, as physicians, we owe it to our families and subsequent generations to see that medicine survives as a profession. We, as physicians, can still do something about this. If you are already a member of AAPS, get others to join. Get a new member to join us each month. By supporting the AAPS, you can stand for the principles of the independent practice of private medicine and the Oath of Hippocrates. We in the AAPS believe that the managed care juggernaut can be halted because there is a major chink in its heavy armor --- the loss of medical ethics.
Today, physicians face the extreme danger of relinquishing their responsibility as advocates of their individual patients, ostensibly, we are told, "for the good of society."
In the guise of doing what is best for society, we are headed toward the concentration of power in the politically-connected and government-favored special interest groups (i.e., big insurers and MCOs megacorporations); toward more regulation while lip-service is paid to free-market capitalism (guided by massive bureaucracies and the directives of the central planners); further collectivization of medical care, like in managed care and HMOs, masquerading as free-market capitalism; toward democratic socialism (with heavy taxation and where wealth redistribution schemes remain deeply entrenched and individual liberties continue to be lost piecemeal) --- all in the guise of fairness and (false) compassion. We are inexorably marching toward the concentration of economic power in the hands of corporate bureaucrats working in collusion with their governmental counterparts; and toward the loss of the erstwhile concepts of (rugged) American individualism, self-reliance, and true sense of community in which this nation was founded. Small businesses and entrepreneurs will be swallowed up by the new corporate magnates and internationalists, protected by the monopolistic tendencies of nearly omnipotent, global, interdependent governments with which they have "partnerships."
Society owes a debt of gratitude to the medical profession for the self-evident miracles of medical progress. In fact, as we prepare for the continuing saga of "incremental health care reform," Americans must be reminded of the truly needed changes in health care, namely providing the proper incentives for individuals to assume responsibilities and pay their way via the private sector with tax-free MSAs; high-deductible catastrophic insurance purchased from the MSA; and perhaps, vouchers for those who cannot truly afford health care coverage (i.e., who have to go without health care for a year or longer), or the reinstitution of charity. We must also provide meaningful medical liability tort reform for practicing physicians, eliminate "hold harmless clauses" for HMOs, and preempt ERISA laws to make MCOs liable for medical malpractice when they practice medicine, as they are currently doing, without a license.
Unfortunately, truly free market, patient-oriented medical care reforms were not the reforms enumerated in President Bill Clinton's Health Security Act of 1993, nor the more recent reforms passed by the Republican-led Congress. The MSA provisions, the only individually-based, true free market alternative, in the Kassebaum-Kennedy bill were written with a cap on the number of accounts that could be started (i.e., 750,000) and other insurance constraints (i.e., arbitrary guidelines, odd deductibles, and more IRS oversight), as if deliberately preordained to failure.
As events today rapidly unravel, it is becoming clear that there are ulterior motives behind the incremental health care reforms. Like Lewis Carroll's fanciful story, Through the Looking Glass, things are not always what they seem. But, one thing is certain. As events unfold, it is becoming evident that the failed Clinton Health Security Act of 1993 is being implemented piecemeal, in an incremental, bipartisan fashion and the real reason is not about access or coverage, quality of care, or even persistently high health care costs. It is about the desire to implement further regimentation and bureaucratization of medical care in lieu of de facto attempted complete government takeover, an attempt which failed in 1994. It is also about political expediency and acquiescence by those presumably on our side who know or should have known better.
I suspect the real reasons for the ever-continuing, incremental health care reform changes being passed by Congress are the same as those of the failed Health Security Act of 1993: (1) the implementation of and consolidation of managed care (corporate socialized medicine) where health care decisions will no longer be made by physicians and their individual patients, but by statist government bureaucrats more concerned with budgets and control, and their counterparts in the private sector health care network megacorporations which are more concerned with the bottom line than the sanctity of human life; and (2) a disingenuous allurement for the seduction of working, prosperous, middle class Americans to make them like the welfare poor, a government-dependent class. Socialist planners know that once the yoke of socialism is harnessed on the beasts of burden, it is virtually impossible to shake off as the experiences in England, Norway, and Sweden amply testify. (3) And from past experience, particularly in Minnesota, the way to gain that beachhead is by the implementation of KidCare followed by subsequent expansion of the program when no one is watching. Afterall, KidCare was the fall back plan of Hillary Clinton and Ira Magaziner to implement Clinton Care and universal coverage piecemeal, if the overall master plan, the Health Security Act, failed.
With corporate socialized medicine fully implemented, physicians would then be compelled to embrace veterinary medical ethics,** following government-written guidelines under government-mandated fees, and acting in the best interest of the state, rather than the patient's. In this scenario, bureaucratic inefficiency, red-tape, medical delays, and other practices, as are commonplace in fully socialized systems, would be the rule rather than the exception.
Members of the legal profession in the plaintiffs bar are attempting (and competing with consumer advocates) to replace the physician, the patient's traditional advocate, as their true and newest protectors --- and they are succeeding. In fact, plaintiff's attorneys are looking more and more like knights in shining armor as they pierce the defensive shield of managed care while striking with malpractice lawsuits where it hurts more, in the MCOs' pocketbooks.(4)
As we approach the 21st Century, it is becoming evident that the survival of the medical profession, as we have known, it will depend on at least two crucial factors: (1) The reinvigoration of the ethics of Hippocrates within the profession, with emphasis placed on the need for virtue-based ethics, while recognizing the need to balance this with the healthy rather than detrimental reality of a physician's enlightened self-interest. (2) A reinstatement of the principle of medical ethics that recognizes that, in considering treatment options and medical decisions inherent to the sacrosanct patient-doctor relationship, the individual interest of the patient --- and not the state, or "society" --- is, and will always be, paramount.
It is the only approach to health care and medical ethics that deals with true individual beneficence rather than coercive state compassion, and cost containment without rationing, by empowering individual patients and their physicians rather than government or corporate bureaucracies.
Managed care and managed competition are unstable entities that will eventually collapse under their own bureaucratic weight, ultimately giving way to either fully socialized medicine (à la Canadian or British, if not former Soviet style) and total government control --- or freedom. In the case of the former, patients will be jolted from the utopic reverie of free health care "that will always be there" to the harsh realities of waiting lists for diagnostic studies, treatments, and surgeries; delisting and rationing of specific services; and, perhaps in the not-too-distant future of a brave new world, active euthanasia, not as magnanimous acts of self-determination as proclaimed by many post-modern ethicists, but rather, as the ultimate form of rationing, rationing by death.(5)
Again, what has led to this state of affairs? In many of my previous writings, I've alluded to the motley of different factors that have adversely impacted medical practice and our profession. Nevertheless, among these factors, one issue seems to recur time and again: medical ethics, or the perversion thereof. All too often, instead of standing by our ideals, persevering in the pursuit of truth, following the time-honored principles set forth in the Oath of Hippocrates, and the ethical tradition of our medical forefathers, we have often been too willing and too eager to transmute the ethical precepts of our profession for the political expediency of the moment, and to apply quick pragmatic solutions in inept and short-sighted attempts at solving the immediate political and ethical conundrums that we face.
As a result (of such activities as supporting political candidates on both sides of the fence and contributing heavily to the campaign coffers of such foes of independent medicine as Rep. Fortney "Pete" Stark [D-CA]), organized medicine led by the AMA has lost considerable influence, not to mention credibility in Washington.
I've been told by at least one defender of this practice that this is "just politics!" That may be, but when we are dealing with the survival of a once respected and trusted profession and defending transcendental principles rooted in ethics, our profession should not compromise.(6)
Before we join the bandwagon of managed care and borrow capital from the AMA to establish our own managed care physician-directed networks, let us remember one of the most outlandish flip-flops of only a few years ago, when physicians were initially given the blessing of the AMA for forming joint ventures, but then later physicians found themselves on shaky ethical and legal ground with the referral of patients to diagnostic or laboratory entities in which they had a vested financial interest. Safe harbors were initially provided, but then Rep. Stark, despite all the AMA financial contributions and giving credit to his integrity, made the harbors unsafe with a storm of legislation which made them neither safe nor navigable.
Modern flexible medical ethics, as promoted explicitly or implicitly by organized medicine, have provided no moral compass for the professional and ethical behavior of physicians. We have already mentioned the large looming issues of the corporate practice of medicine and joint ventures. The AMA also provided the embarrassing flip-flop over support for employer mandates during the great health care debate of 1993-1994, which confounded friends and foes alike; and the explicit contradiction between the obligation to treat or not to treat AIDS patients and the AMA's own Code of Ethics, Principle VI, asserting the right of free association. And, there were also the troublesome items of contention as the sanctimonious ruling against the acceptance of trinkets and free drug samples by individual physicians from the pharmaceutical industry, self and family treatment for minor illnesses, and the extension of professional courtesy to colleagues and their families, etc., which constitute a slap to the integrity of physicians. And now, to add insult to injury, the AMA, as I have mentioned previously, in a supreme act of hypocrisy, plunged head long into the commercial endorsement and multimillion dollar business fiasco with the Sunbeam Corporation.
So, physicians should think twice before forming their own managed care networks. I caution you because if you do join these ventures, you will be traversing perilous waters, and, sooner than you think, you may find yourself in unsafe harbors and haunted by troubling questions of impropriety (and perhaps even illegalities).
And, given the AMA's past record on these tough, gray-zone areas of medical ethics, I have a final caveat emptor for those of you who plan to jump aboard this latest maritime adventure, and that is, when the ship begins sinking and is quickly scuttled in ethical and legal rough seas, don't expect the AMA and organized medicine to be there to throw you a life preserver!(6)
* I have coined the term flexible (medical) ethics to refer to the post-Modern justification and application of the situational ethics of the moment and the exculpatory moral relativism of the times by the leaders of organized medicine to make traditional medical ethics fit their political, pragmatic, decision-making process.
** Veterinary medical ethics is the term used by the Swiss medical philosopher Ernest Truffer who has decried the increasing interference of third-parties between patient and doctor which "amounts to a rejection of the [traditional] medical ethic, which is to care for a patient according to the patient's specific medical requirement, in favor of a veterinary ethic, which consists of caring for the sick animal not in accordance with its specific medical need, but according to the requirement of its master and owner, the person responsible for meeting any costs incurred." This is no affront to veterinary medicine, as Prof. Ernest Truffer, the originator of this concept wrote me --- the nature of the two professions are different.
1. AMA reimbursement. Physicians Weekly, July 21, 1997.
2. Faria MA Jr. Vandals at the Gates of Medicine - Historic Perspectives On the Battle Over Health Care Reform. Macon, Georgia, Hacienda Publishing, Inc., 1995, p.206.
3. Ibid., p.262-263.
4. News Capsule: Managed care shield pierced. Medical Sentinel 1997;2(3):78.
5. Faria, op. cit., pp. 240-242.
6. Faria MA Jr. Medical Warrior --- Fighting Corporate Socialized Medicine. Macon, Georgia, Hacienda Publishing, Inc., 1997, pp. 164, 167-168.
Dr. Faria is a consultant neurosurgeon and author of Vandals at the Gates of Medicine (1995) and Medical Warrior: Fighting Corporate Socialized Medicine (Macon, Georgia, Hacienda Publishing, Inc, 1997). He was also Editor-in-Chief of the Medical Sentinel.
This article may be cited as: Faria MA. The Transformation of Medical Ethics Through Time (Part II): Medical Ethics and Organized Medicine the Medical Sentinel 1998;3(2):53-56. Available from: http://www.haciendapublishing.com/medicalsentinel/transformation-medical-ethics-through-time-part-ii-medical-ethics-and-organized-medi
Copyright ©1998 Miguel A. Faria, Jr., M.D.