Li, James T. C. MD PhD
Many physicians are acutely aware of the external forces that are threatening the medical profession. Most of these forces are direct results of attempts to control health-care costs.
Although medical information science, quality improvement, and practice guidelines all have the potential to improve the quality of medical care, in practice, cost-containment strategies often ultimately degrade the patient-physician relationship. In some managed-care settings, the clinical encounter is deliberately ``managed''; thus, the physician's interests are at odds with the patient's interests. Central to this notion is the destruction of the traditional patient-physician relationship in which the interests of the patients come first. For example, in some managed-care organizations, physicians are required to sign a loyalty oath and gag order. The loyalty is to the managed-care organization, and the gag order is for patients. These orders prohibit or limit clinically meaningful discussion with patients. When these rules are coupled with payment schemes that reimburse physicians to limit care, they dramatically undermine the trust between the patient and the physician.
Managed-care organizations should not be blamed for these cost-containment measures. After all, the directors of a for-profit corporation have a fiduciary duty to put the interests of shareholders over their own interests and the interests of their employees. The fiduciary relationship, between director and shareholder or between a trustee and a beneficiary, is held to extremely high ethical standards. Executives in managed-care corporations should not be criticized for putting the needs of their stockholders first. In fact, this fiduciary relationship should be supported and honored.
Physicians, however, should be faulted for submitting to external pressures and for betraying the trust granted to them by their patients. The relationship between the patient and the physician is based on the expectation that the physician will put the needs of the patient first--over and beyond the interests of the physician or any third party. This relationship is the foundation on which the practice of medicine is built and dates back to the era of Hippocrates and Asklepios in ancient Greece (1,500 B.C. to 500 B.C.). [1] The relationship between patient and physician should be held to a standard at least as high as the fiduciary relationship between director and shareholder.
Physicians have not always upheld their responsibility to put the needs of the patient first. The well-being of patients and the profession of medicine have suffered when physicians have put their own interests or the interests of a third party before the interests of their patients. Greed, prestige, and power have all succeeded at some time in displacing patients as the top priority of physicians. These lessons from history are relevant today.
When the pursuit of wealth or money becomes the first priority of physicians in a fee-for-service environment, patients may be subjected to unnecessary diagnostic tests or therapeutic interventions. In a capitated payment environment, concern about the protection of the physician's own livelihood can lead to withholding clinically needed care.
When the pursuit of fame or prestige becomes the first priority of physician-investigators, patients may undergo dangerous and life-threatening experimentation. The single-minded goal of scientific achievement, even without the temptations of fame or prestige, can be an equally false priority of physician-investigators. The history of medical research during the current century is riddled with examples of scientific misconduct and ethical lapses. The infamous Tuskegee syphilis study is but one example.
Patients, the medical profession, and society all suffer when the interests of a third party become the first priority of physicians. The third party can be the physician's employer, a political party, or the government. For example, physicians in the United States have done harmful experiments with radiation and toxic chemicals on unsuspecting persons for the benefit of the government.
The most horrific example of physicians' abandonment of patients is the central role of physicians in the Third Reich; after 1933 in Germany and 1938 in Austria, half of all physicians were members of the Nazi party. [2] Many of these physicians, often prominent in the academic community, were also leaders and perpetrators of eugenics, euthanasia, and mass murder programs; recall the image of the physician acting as gatekeeper and triage officer at the concentration camps. Although some physicians cried out against the pogroms, many were silent. Others capitalized on employment opportunities made available by the disappearance of Jewish physicians. [3]
Although no parallel exists between physicians' behavior in the Third Reich and physicians' behavior today, important lessons can be learned by contemporary physicians. Dr. Jordan J. Cohen discussed the conference entitled ``Hippocrates Betrayed: Medicine in the Third Reich'' held on the 50th anniversary of the Nuremberg Doctor's Trial. [4] The conference ``explored the antecedents of the contemporary relationship between physicians and the state through an historical analysis of the roots of Nazi medicine four dot bond'' He declared that medicine can survive and flourish only if physicians exercise constant vigilance to ensure that medical science is used only for service to humanity. This vigilance must include resistance to the temptations of wealth, prestige, and power. Some of the excesses previously described may not have occurred if physicians had remembered their obligation to put patients first and if they had had the courage and strength to act on this principle.
In the spirit of such vigilance, I suggest that each physician examine his actions by addressing three questions.
1. Are you a caregiver or a gatekeeper? The caregiver provides care and concern to a person in need, healing if possible, helping always. To sick persons, the caregiver is ``a guide through some of life's most difficult journeys.'' [5] In contrast, the gatekeeper minds the gate, letting some persons through and keeping others out. The function of the gate is to restrict access. The gatekeeper serves the interests of the owner of the gate not of the people trying to get through the gate. Physicians are just beginning to realize that the gatekeeper serves entirely at the whim of the owner of the gate.
2. Which principle governs your relationship with the patient: morality or the marketplace? The term ``morality'' refers to the basic human concept of right and wrong. For physicians, morality means doing what is right for our patients and speaking or acting out against what is wrong. No such moral absolute can be found in the marketplace. The market is driven by revenue, profit margins, and market share. No patients exist in a market-driven practice of medicine--only consumers for whom the watchword is caveat emptor.
A great danger to the practice of medicine is the transformation of physicians to interchangeable, dispensable workers accountable only to their employers and the financial performance of the institution that employs them. In this setting, physicians and health care are simply commodities--cold and without compassion. The greatest danger, however, is not loss of the physician's autonomy, degradation of the profession of medicine, or transformation of health care to a commodity. The greatest danger is the transformation of the patient to the status of commodity. The lessons from history are particularly instructive on this point.
In the Hippocratic model of medicine, the patient represents a vulnerable person in need--the first and only priority of the physician. In the commercial model of medicine, the patient is at best a consumer; at worst, the patient is a source of revenue when well and a source of medical (financial) losses when sick. In a capitated, commercial system, physicians and managed-care organizations have every financial reason to shun sick people. In this system, physicians make economic (not clinical) decisions and provide medical explanations for those decisions. Patients are left to fend for themselves and to face the consequences alone.
3. What is the relationship between you and your patient? Is it a covenant or a contract? A group of clinical ethicists defined the practice of medicine as ``a moral enterprise grounded in a covenant of trust.'' [6] Webster's Ninth New Collegiate Dictionary defines covenant as a ``formal, solemn, and binding agreement.'' For a more complete understanding of the term ``covenant,'' we must return to our professional ancestors in ancient Greece. During the time of Hippocrates, the Greek term for covenant (diatheke) was not used to describe a usual agreement or contract between two parties. The term ``diatheke'' was used almost exclusively to signify a very special relationship--a will and testament.
A last will and testament involves parties who have a special and close relationship with each other; a contract involves strangers. A last will and testament is based on trust; a contract is based on mistrust. A last will and testament is a relationship between two unequal parties in which one party is concerned about the welfare of the other. A contract is between two equal parties, each concerned only with his own welfare. In its essence, a will and testament is a beneficent promise, a trust offered by one party to another. For physicians, this promise is to put the interests and needs of the patient first. The term ``covenant'' aptly describes the relationship between patient and physician. Physicians should have the conviction and courage to defend this covenant not only against external threats but also against internal threats of fear, ignorance, and complacency.
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2. Wiesenthal S. Justice Not Vengeance. London: Weidenfeld and Nicolson, 1989 [Context Link]
3. Lifton RJ. The Nazi Doctors. New York: Basic Books, 1986 [Context Link]
4. Cohen JJ. An awesome responsibility for medical educators. Acad Physician Sci 1996 Mar; 8 [Context Link]
5. Bernardin J. Reflections on `moral crisis' gripping medical profession. Am Med News 1996 Feb 5; 39:18 [Context Link]
6. Cassel CK. The patient-physician covenant: an affirmation of Asklepios [editorial]. Ann Intern Med 1996; 124:604-606 [Fulltext Link] [Medline Link] [Context Link]