By Wesley J. Smith
Editor’s note. This appears on Wesley’s fine blog.
Increasingly the medical intelligentsia are pushing a dual mandate on physicians in the name of cutting costs–one to patients and one to society–and when they conflict, many want the individual’s needs to be subsumed to the collective. This attempt to redefine medical professionalism must be resisted at all turns.
The latest example of such advocacy appears in the New England Journal of Medicine, one of the most energetic pushers of the “new medicine.” From “The Doctor’s Dilemma–What is Appropriate Care?” by Victor R. Fuchs, Ph.D.:
Most physicians want to deliver “appropriate” care. Most want to practice “ethically.” But the transformation of a small-scale professional service into a technologically complex sector that consumes more than 17% of the nation’s gross domestic product makes it increasingly difficult to know what is “appropriate” and what is “ethical.”…
In an effort to address this issue, physicians’ organizations representing more than half of all U.S. physicians have endorsed a “Physician Charter” that commits doctors to “medical professionalism in the new millennium.” The charter states three fundamental principles, the first of which is the “primacy of patient welfare.” It also sets out 10 “commitments,” one of which states that “while meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources.” How can a commitment to cost-effective care be reconciled with a fundamental principle of primacy of patient welfare?
They can’t because once a doctor decides that what might be optimal care for the patient would interfere with his or her supposed professional obligation to the whole, he or she has entered conflict of interest territory. Fuchs sees this, but merely seeks to redefine what constitutes “appropriate” care:
There is no escaping the fact that many interventions are valuable for some patients even if, for the population as a whole, their cost is greater than their benefit…If the physician is paid on a fee-for-service basis and the patient has open-ended insurance, the scales are tipped in favor of doing as much as possible and against limiting interventions to those that are cost-effective….
In contrast, if the physician is practicing in a setting that has accepted responsibility for the health of a defined population and the organization receives an annual fee per enrollee, the chances of the physician’s practicing cost-effective medicine are substantially increased, even though all patients are insured…In short, when physicians are collectively caring for a defined population within a fixed annual budget, it is easier for the individual physician to resolve the dilemma in favor of cost-effective medicine [Me: and against the interest of the individual patient.] That becomes “appropriate” care. And it is an ethical choice, as defined by philosopher Immanuel Kant, because if all physicians act the same way, all patients benefit.
What sophistry. The patient deprived of optimal care doesn’t benefit, and hence, by definition, “all” patients do not benefit. This is just a call for ad hoc rationing at the bedside.
Doctors owe fiduciary duties to individual patients, not “groups,” and certainly not general society. That is the very heart of being a “professional.” That duty should not depend on how doctors get paid. These intellectuals are devolving medicine into a technocracy. In doing so, they are playing with fire. Once the people’s trust is destroyed, like Humpty-Dumpty, it will be almost impossible to put it back together again.