I know I have already taken two chapters to discuss corruption in medicine; however, when it comes to the health of our citizens and greed, you can’t devote enough space to this subject. I could probably devote an entire book to the topic. Maybe I will do it when I retire, and I am free to speak without the fear of losing my license or my job..

Money and Medicine: Indivisible and Irreconcilable

Eli Y. Adashi, MD, MS

First, there was barter. A well-cooked meal for a lanced boil. Cords of wood for a home visit. A chimney sweep was treated for gas. And then there was commodity money such as tobacco, not to mention wampum. However, with specie and paper money on the rise in the New World colonies, barter was increasingly being relegated to a historic footnote. The outright innocence of it all notwithstanding, the ethics of barter and medicine in days of yore were most likely just as challenging as ethics are at present with contemporary monetary counterparts. The constancy of the fundamentals of human nature would have seen to that. Still, medicine was not all that present in most people’s lives. Few users. Few providers. This constrained transactional scope all but precluded the notion of medicine as a business on a grand scale. Interestingly, this steady state of “cash for care” had held sway through centuries during which physicians occupied a lofty perch. The twentieth century changed all that. This commentary explores the potential ethical fallout from the contemporary juxtaposition of money and medicine in the practice, business, and industry arenas.

The Rise of Fee for Service

Ironically, it was the advent of the employer-sponsored health insurance paradigm and its “fee-for-service” payment system that ushered in the contemporary business of medicine and the ethical challenges thereof. Under this system, patients were kept in the dark about the going rates for health care services. Details of the latter were the proprietary domain of physicians and payers. Confidentially negotiated agreements saw to that. What is more, patients were not assigned the responsibility of paying the bills for medical services rendered, the accountability for which had been assumed by their employers. Having been taken off the proverbial financial hook, patients broadly embraced the newly inaugurated third-party insurance universe, wherein the conspicuous provision and consumption of health care services became the new normal. For their part, physicians did their very best to accommodate the growing demand. Aided and abetted by fee-for-service payment policies, the new world order now linked physician reimbursement to the volume of units of service rendered, thereby establishing medicine as a retail business. Happily uninformed—indeed blissfully oblivious—patients offered no resistance and did little to douse the flames of overconsumption. A culture antithetical to “choosing wisely” ensued, wherein the need to “bend the cost curve” became increasingly urgent. It will be some time before current efforts at reform reestablish measures of accountability and discernment.

Money and Medicine in the Practice Arena

Stripped to its core, medicine is a service industry, the product of which is health care. As such, the practice of medicine, not unlike the provision of any other service, is deserving of professional remuneration. Viewed in this light, medicine and money are sensibly interrelated and by extension indivisible. Less clarity exists, however, about the question of whether medicine should be a conduit to wealth accumulation. To its proponents, the notion of medicine as the road to personal wealth constitutes just another example of free-market economics. Medicine, after all, is but another form of business, and conflicts of interest never enter the equation, given a self-regulated, unswerving clinical decision-making process. To its detractors, the notion of self-enrichment from the practice of medicine represents an example of capitalism gone awry. According to this outlook, striving for riches in the healing professions is rife with financial conflicts of interest, with clouded clinical judgments, and with a compromised professional posture. Examined in this light, medicine and money appear irreconcilable. Cautionary sentiments along these lines have reverberated over the ages. The twelfth-century Physician Oath of Maimonides offers the hope “may neither avarice, nor miserliness…engage my mind”. The fifteenth-century Oath of Vaidya, intended for Hindu physicians, offers the admonition “You must put behind you…greed”. The sixteenth-century Rules of Enjuin lay out a comparable line of reasoning wherein Japanese physicians are counselled against “avarice”. The above notwithstanding, several other physician oaths and pledges make no mention of the subject. Notable examples include but are not limited to the Hippocratic Oath, the Physician’s Oath (The Declaration of Geneva), and the Oath of Asaph whether or not the authors of the latter three attestations deemed money and medicine to be reconcilable is unknowable.

As a matter of course, the practice of medicine comprises both specialty and primary care disciplines. In general, the former, especially the surgical varieties, are more remunerative than the latter. It follows that greater financial returns from the practice of medicine are more likely in the specialties than they are in the primary care arena. This conclusion appears to be particularly applicable to the “cash-only” segment of medicine exemplified by the subspecialties of plastic surgery and cosmetic dermatology and some subspecialties of assisted reproductive care, to name a few. As such, it is hardly surprising that a body of peer-reviewed contributions highlights the role of debt in the career choices made by medical school graduates. It follows that decisions at the earliest stages of a medical career may be guided not only by professional preferences but also by the need to address financial realities and goals.

Money and Medicine in the Business Arena

Medicine and money become further entangled when the role of the physician-entrepreneur is considered. Herein, the focus is on the business rather than on the practice of medicine. The literature is largely mum on the pervasiveness of this preoccupation among actively practicing physicians, although the fraud and abuse literature suggests that only a vanishingly small fraction is involved. Still, physician ownership of health care businesses constitutes a growing reality deserving of mention. As it stands, physicians are invested in pharmacies, distributorships, toxicology laboratories, pathology laboratories, surgery centers, imaging centers, radiation therapy centers, physical therapy centers, and sperm or egg banks, to name a few health care enterprises. Physicians also invest in and own hospitals and group purchasing organizations.

As going business concerns owned and operated by nonphysicians, the enterprises mentioned above raise little or no concern. In contrast, physician-owned and -operated health care enterprises have been the subject of federal scrutiny for the better part of three decades. In most, if not all, cases, concerns have revolved around the practice of self-referral and the possibility of an attendant financial conflict of interest. Restrictive covenants followed. The Stark Laws (“Physicians’ Ownership of and Referral to Health Care Entities”) of 1989 and 1993 targeted self-referrals to physician-owned outpatient facilities. More recently, section 6001 of the Affordable Care Act (“Limitation on Medicare Exception to the Prohibition on Certain Physician Referrals for Hospitals”) set its sights on physician-owned hospitals. To proponents of medicine as a business, physician-entrepreneurs are merely a sign of the times. Viewed in this light, physician self-referral represents a patient-centered care-enhancing proposition. To its detractors, self-referral is ethically challenging, possibly unnecessary, and potentially harmful. On this plane, never the twain shall meet, let alone reconcile.

Money and Medicine in the Industry Arena

Another frontier whereon medicine and money have been vying for a modus vivendi is the interface between medicine and its industry partners. Herein, concerns revolve around the possibility that financial ties to manufacturers of drugs, devices, biologics, and medical supplies will influence clinical decision making. Payment categories in this context may include, but need not be limited to, royalty, licensing, promotional speaking, consulting, and research. Physician ownership and investments in industrial concerns have also come to the attention of regulators. Importantly, this intersection of money and medicine has, not unlike the self-referral phenomenon, been the subject of substantial federal scrutiny. Long-standing drives to enumerate and report the financial transactions between physicians and industry have finally been consummated with the implementation of section 6002 (“Transparency Reports and Reporting of Physician Ownership or Investment Interests”) of the Affordable Care Act, also known as the “Physician Payments Sunshine Act”. As a result, physician-industry financial interactions are now largely transparent and publicly listed. What is more, significant tightening of the financial conflict-of-interest rules associated with industry-funded continuing medical education has further attenuated the economic dimension of the medicine-industry interface. The same appears to hold for the all-out exclusion of pharmaceutical sales representatives from most physician offices and health care facilities. Finally, author disclosure requirements of industry support have been introduced to assure the integrity of the peer-reviewed literature. These policies are presently undergoing reevaluation.

In a 1992 editorial, the late Arnold S. Relman, MD, then editor of the New England Journal of Medicine, singled out physician self-referral as a prime example of the “growing encroachment of commercialism on medical practice”, which he termed the “medical-industrial complex”. A highly influential thesis, this far-reaching observation has withstood the test of time. However, its impact on the commercialization of medicine and on the attendant ethical fallout remains debatable. Consider the matter of self-referral. The detrimental consequences of self-referral are well documented. However, opinions as to its value and its ethical implications remain as irreconcilable as ever.

Going forward, physician reimbursement will be altered by the anticipated dismantling of the “fee-for-volume” payment system and its substitution with “fee-for-value” alternatives. Whether or not a momentous alteration of the economic ground rules on this scale will in effect change hearts and minds remains doubtful. More than likely, money and medicine will remain both indivisible and irreconcilable for some time to come. Few expect otherwise.

The relationship between ethics and monetary gain in medicine presents a constant tension. While medicine is a service industry where healthcare professionals deserve fair compensation, the pursuit of profit should never compromise patient well-being or ethical principles. Ideally, the primary focus should be on the patient’s welfare, with financial considerations being secondary. 

Here’s a breakdown of the key aspects:

1. The Core Principle: Patient Welfare First

• Beneficence and Non-maleficence: The fundamental ethical principles of medicine, beneficence (doing good) and non-maleficence (avoiding harm), should always guide medical decisions. 
• Conflicts of Interest: Physicians must be aware of potential conflicts of interest where financial gains might influence their clinical judgment. 
• Prioritizing Patient Needs: In any conflict between financial interests and patient welfare, the patient’s needs must take priority. 

2. Balancing Financial Needs and Ethical Obligations

• Remuneration is Necessary: Doctors, like other professionals, deserve to be compensated for their services and expertise. 
• Ethical Practice: Striving for financial gain should not lead to unethical practices like providing unnecessary or wasteful treatments solely for profit. 
• Transparency and Openness: Open communication about costs, treatment options, and potential financial implications can help patients make informed decisions. 

3. Ethical Concerns in the Commercialization of Healthcare

• Profit Motive: The increasing commercialization of healthcare raises concerns about whether the pursuit of profit can undermine the core values of medicine. 
• Access to Care: Some argue that a focus on profit can exacerbate existing inequalities in access to healthcare, particularly for vulnerable populations. 
• Quality of Care: There are concerns that profit-driven healthcare systems may prioritize cost-cutting measures that could compromise the quality of care. 

4. Examples of Ethical Dilemmas

• Gifts from Pharmaceutical Companies: Physicians must be mindful of potential biases introduced by gifts or other inducements from pharmaceutical companies. 
• “VIP” Treatment: Providing preferential treatment based on a patient’s financial status can be seen as unethical and unfair. 
• Access to Care: Ensuring equitable access to healthcare services for all, regardless of their ability to pay, is a significant ethical challenge. 

5. Moving Forward

• Education and Training: Ethical considerations should be integrated into medical education and training to equip future physicians with the tools to navigate these complex issues, according to the Santa Clara University. 
• Professional Codes of Conduct: Strong professional codes of conduct and regulatory oversight are crucial for maintaining ethical standards in healthcare. 
• Focus on Patient Outcomes: Ultimately, the success of a healthcare system should be measured by its ability to improve patient outcomes, not just its financial performance. 

Ethics, Morality, and Professional Standards

Ethics is a broad term that covers the study of the nature of morals and the specific moral choices to be made. Normative ethics attempts to answer the question, “Which general moral norms for the guidance and evaluation of conduct should we accept, and why?” [5]. Some moral norms for right conduct are common to human kind as they transcend cultures, regions, religions, and other group identities and constitute common morality (e.g., not to kill, or harm, or cause suffering to others, not to steal, not to punish the innocent, to be truthful, to obey the law, to nurture the young and dependent, to help the suffering, and rescue those in danger). Particular morality refers to norms that bind groups because of their culture, religion, profession and include responsibilities, ideals, professional standards, and so on. A pertinent example of particular morality is the physician’s “accepted role” to provide competent and trustworthy service to their patients. To reduce the vagueness of “accepted role,” physician organizations (local, state, and national) have codified their standards. However, complying with these standards, it should be understood, may not always fulfill the moral norms as the codes have “often appeared to protect the profession’s interests more than to offer a broad and impartial moral viewpoint or to address issues of importance to patients and society” [6].

Bioethics and Clinical (Medical) Ethics

A number of deplorable abuses of human subjects in research, medical interventions without informed consent, experimentation in concentration camps in World War II, along with salutary advances in medicine and medical technology and societal changes, led to the rapid evolution of bioethics from one concerned about professional conduct and codes to its present status with an extensive scope that includes research ethics, public health ethics, organizational ethics, and clinical ethics.

Hereafter, the abbreviated term, ethics, will be used as I discuss the principles of clinical ethics and their application to clinical practice.

The Fundamental Principles of Ethics

Beneficence, nonmaleficence, autonomy, and justice constitute the four principles of ethics. The first two can be traced back to the time of Hippocrates, “to help and do no harm,” while the latter two evolved later. Thus, in Percival’s book on ethics in the early 1800s, the importance of keeping the patient’s best interest as a goal is stressed, while autonomy and justice were not discussed. However, with the passage of time, both independence and justice gained acceptance as essential principles of ethics. In modern times, Beauchamp and Childress’ book on Principles of Biomedical Ethics is a classic for its exposition of these four principles and their application, while also discussing alternative approaches.

Beneficence

The principle of beneficence is the obligation of a physician to act for the benefit of the patient. It supports several moral rules to protect and defend the rights of others, prevent harm, remove conditions that will cause damage, help persons with disabilities, and rescue persons in danger. It is worth emphasizing that, in distinction to nonmaleficence, the language here is one of positive requirements. The principle calls for not just avoiding harm, but also benefiting patients and promoting their welfare. While physicians’ beneficence conforms to moral rules and is altruistic, it is also true that in many instances it can be considered a payback for the debt to society for education (often subsidized by governments), ranks and privileges, and to the patients themselves (learning and research).

Nonmaleficence

Nonmaleficence is the obligation of a physician not to harm the patient. This simple principle underpins several moral rules: do not kill, do not cause pain or suffering, do not incapacitate, do not cause offense, and do not deprive others of the goods of life. The practical application of nonmaleficence is for the physician to weigh the benefits against the burdens of all interventions and treatments, to eschew those that are inappropriately burdensome, and to choose the best course of action for the patient. This is particularly important and pertinent in difficult end-of-life care decisions on withholding and withdrawing life-sustaining treatment, medically administered nutrition and hydration, and in pain and other symptom control. A physician’s obligation and intention to relieve the suffering (e.g., refractory pain or dyspnea) of a patient by the use of appropriate drugs, including opioids, overrides the foreseen but unintended harmful effects or outcome (doctrine of double effect).

Autonomy

The philosophical underpinning for autonomy, as interpreted by philosophers Immanuel Kant (1724–1804) and John Stuart Mill (1806–1873), and accepted as an ethical principle, is that all persons have intrinsic and unconditional worth, and therefore, should have the power to make rational decisions and moral choices, and each should be allowed to exercise his or her capacity for self-determination. This ethical principle was affirmed in a court decision by Justice Cardozo in 1914 with the epigrammatic dictum, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body”.

Autonomy, as is genuine for all four principles, needs to be weighed against competing moral principles, and in some instances may be overridden; an obvious example would be if the autonomous action of a patient causes harm to another person. The principle of autonomy does not extend to persons who lack the capacity (competence) to act autonomously; examples include infants and children, and incompetence due to developmental, mental, or physical disorder. Health-care institutions and state governments in the US have policies and procedures to assess incompetence. However, a rigid distinction between incapacity to make health-care decisions (evaluated by health professionals) and incompetence (determined by the court of law) is not of practical use, as a clinician’s determination of a patient’s lack of decision-making capacity based on physical or mental disorder has the same practical consequences as a legal determination of incompetence.

Detractors of the principle of autonomy question the focus on the individual and propose a broader concept of relational autonomy (shaped by social relationships and complex determinants such as gender, ethnicity, and culture). Even in an advanced Western country such as the United States, where the culture is inhomogeneous, some minority populations hold views different from those of the majority white population, in need of full disclosure, and in decisions about life support (preferring a family-centered approach).

Resistance to the principle of patient autonomy and its derivatives (informed consent, truth-telling) in non-Western cultures is not unexpected. In countries with ancient civilizations, rooted beliefs and traditions, the practice of paternalism (this term will be used in this article, as it is well-entrenched in ethics literature, although parentalism is the proper term) by physicians emanates mainly from beneficence. However, culture (a composite of the customary beliefs, social forms, and material traits of a racial, religious, or social group) is not static and autonomous, and changes with other trends over the passing years. It is presumptuous to assume that the patterns and roles in physician-patient relationships that have been in place for half a century or more still hold. Therefore, a critical examination of paternalistic medical practice is needed for reasons that include technological and economic progress, improved educational and socioeconomic status of the populace, globalization, and societal movement towards emphasis on the patient as an individual rather than as a member of a group. This examination can be accomplished through research that includes well-structured surveys on demographics, patient preferences regarding informed consent, truth-telling, and their role in decision-making.

Respecting the principle of autonomy obliges the physician to disclose medical information and treatment options that are necessary for the patient to exercise self-determination and supports informed consent, truth-telling, and confidentiality.

Informed Consent

The requirements of informed consent for a medical or surgical procedure, or for research, are that the patient or subject must be competent to understand and decide, receive a full disclosure, comprehend the disclosure, act voluntarily, and consent to the proposed action.

The universal applicability of these requirements, rooted and developed in Western culture, has met with some resistance and a suggestion to craft a set of requirements that accommodate the cultural mores of other countries. In response and vigorous defense of the five requirements of informed consent, Angell wrote, “There must be a core of human rights that we would wish to see honored universally, despite variations in their superficial aspects …The forces of local custom or local law cannot justify abuses of certain fundamental rights, and the right of self-determination on which the doctrine of informed consent is based is one of them”.

As competence is the first of the requirements for informed consent, one should know how to detect incompetence. Standards (used singly or in combination) that are generally accepted for determining incompetence are based on the patient’s inability to state a preference or choice, inability to understand one’s situation and its consequences, and inability to reason through a consequential life decision.

In a previously autonomous, but presently incompetent patient, his/her previously expressed preferences (i.e., prior autonomous judgments) are to be respected. Incompetent (non-autonomous) patients and previously competent (autonomous), but presently incompetent patients, would need a surrogate decision-maker. In a non-autonomous patient, the surrogate can use either a substituted judgment standard (i.e., what the patient would wish in this circumstance and not what the surrogate would wish) or a best interests standard (i.e., what would bring the highest net benefit to the patient by weighing risks and benefits). Snyder and Sulmasy, in their thoughtful article, provide a practical and functional option when the surrogate is uncertain of the patient’s preferences, or when the patient’s preferences have not kept abreast of scientific advances. They suggest the surrogate use “substituted interests,” that is, the patient’s authentic values and interests, to base the decision.

Truth-Telling

Truth-telling is a vital component in a physician-patient relationship; without this component, the physician loses the trust of the patient. An autonomous patient has not only the right to know (disclosure) of his/her diagnosis and prognosis, but also has the option to forgo this disclosure. However, the physician must know which of these two options the patient prefers.

In the United States, full disclosure to the patient, however grave the disease is, is the norm now, but was not so in the past. Significant resistance to full disclosure was highly prevalent in the US, but a marked shift has occurred in physicians’ attitudes on this. In 1961, 88% of physicians surveyed indicated their preference to avoid disclosing a diagnosis; in 1979, however, 98% of surveyed physicians favored it. This marked shift is attributable to many factors that include, with no order of importance implied, educational and socioeconomic progress, increased accountability to society, and awareness of previous clinical and research transgressions by the profession.

Importantly, surveys in the US show that patients with cancer and other diseases wish to have been fully informed of their diagnoses and prognoses. Providing full information, with tact and sensitivity, to patients who want to know should be the standard. The sad consequences of not telling the truth regarding a cancer include depriving the patient of an opportunity for completion of important life-tasks: giving advice to, and taking leave of loved ones, putting financial affairs in order, including division of assets, reconciling with estranged family members and friends, attaining spiritual order by reflection, prayer, rituals, and religious sacraments.

In contrast to the US, full disclosure to the patient is highly variable in other countries. A continuing pattern in non-Western societies is for the physician to disclose the information to the family and not to the patient. The likely reasons for resistance of physicians to convey bad news are concern that it may cause anxiety and loss of hope, some uncertainty on the outcome, or belief that the patient would not be able to understand the information or may not want to know. However, this does not have to be a binary choice, as careful understanding of the principle of autonomy reveals that autonomous choice is a right of a patient, and the patient, in exercising this right, may authorize a family member or members to make decisions for him/her.

Confidentiality

Physicians are obligated not to disclose confidential information given by a patient to another party without the patient’s authorization. An obvious exception (with implied patient authorization) is the sharing of medical information for the care of the patient from the primary physician to consultants and other health-care teams. In modern hospitals with multiple testing points and consultants, and the use of electronic medical records, there has been an erosion of confidentiality. However, individual physicians must exercise discipline in not discussing patient specifics with their family members or in social gatherings and on social media. There are some noteworthy exceptions to patient confidentiality. These include, among others, legally required reporting of gunshot wounds and sexually transmitted diseases, and exceptional situations that may cause significant harm to another (e.g., epidemics of infectious diseases, partner notification in HIV disease, relative notification of certain genetic risks, etc.).

Justice

Justice is generally interpreted as fair, equitable, and appropriate treatment of persons. Of the several categories of justice, the one that is most pertinent to clinical ethics is distributive justice. Distributive justice refers to the fair, equitable, and appropriate distribution of health-care resources determined by justified norms that structure the terms of social cooperation. How can this be accomplished? There are different valid principles of distributive justice. These are distributions to each person an equal share, according to need, according to effort, according to contribution, according to merit, and according to free-market exchanges. Each principle is not exclusive and can be, and often is, combined in application. It is easy to see the difficulty in choosing, balancing, and refining these principles to form a coherent and workable solution to distribute medical resources.

Although this weighty health-care policy discussion exceeds the scope of this review, a few examples on issues of distributive justice encountered in hospital and office practice need to be mentioned. These include the allocation of scarce resources (equipment, tests, medications, organ transplants), care for uninsured patients, and the allocation of time for outpatient visits (equal time for every patient, based on need or complexity, or social and/or economic status?). Difficult as it may be, and despite the many constraining forces, physicians must accept the requirement of fairness contained in this principle. Fairness to the patient assumes a role of primary importance when there are conflicts of interest. A flagrant example of violation of this principle would be when a particular option of treatment is chosen over others, or an expensive drug is selected over an equally effective but less expensive one because it benefits the physician, financially or otherwise.

Conflicts between Principles

Each one of the four principles of ethics is to be taken as a prima facie obligation that must be fulfilled, unless it conflicts, in a specific instance, with another principle. When faced with such a conflict, the physician has to determine the actual obligation to the patient by examining the respective weights of the competing prima facie commitments based on both content and context. Consider an example of a conflict that has an easy resolution: a patient in shock treated with urgent fluid-resuscitation and the placement of an indwelling intravenous catheter caused pain and swelling. Here, the principle of beneficence overrides that of nonmaleficence. Many of the conflicts that physicians face, however, are much more complex and challenging. Consider a competent patient’s refusal of a potentially life-saving intervention (e.g., instituting mechanical ventilation) or request for a potentially life-ending action (e.g., withdrawing mechanical ventilation). Nowhere in the arena of ethical decision-making is conflict as pronounced as when the principles of beneficence and autonomy collide.

Beneficence has enjoyed a historical role in the traditional practice of medicine. However, giving it primacy over patient autonomy is paternalism that makes a physician-patient relationship analogous to that of a father/mother to a child. A parent may refuse a child’s wishes and influence them through various means, including nondisclosure, manipulation, deception, coercion, and other methods, all in line with their understanding of what is best for the child. Paternalism can be further divided into soft and hard.

In soft paternalism, the physician acts on grounds of beneficence (and, at times, nonmaleficence) when the patient is nonautonomous or substantially nonautonomous (e.g., cognitive dysfunction due to severe illness, depression, or drug addiction). Soft paternalism is complicated because of the difficulty in determining whether the patient was nonautonomous at the time of decision-making but is ethically defensible as long as the action is in concordance with what the physician believes to be the patient’s values. Hard paternalism is action by a physician, intended to benefit a patient, but contrary to the voluntary decision of an autonomous patient who is fully informed and competent, and is ethically indefensible.

On the other end of the scale of hard paternalism is consumerism, a rare and extreme form of patient autonomy, that holds the view that the physician’s role is limited to providing all the medical information and the available choices for interventions and treatments. In contrast, the fully informed patient selects from the available options. In this model, the physician’s role is constrained, and does not permit the full use of his/her knowledge and skills to benefit the patient, and is tantamount to a form of patient abandonment and therefore is ethically indefensible.

Faced with the contrasting paradigms of beneficence and respect for autonomy and the need to reconcile these to find a common ground, Pellegrino and Thomasma argue that beneficence can be inclusive of patient autonomy as “the best interests of the patients are intimately linked with their preferences,” from which “are derived our primary duties to them.”

One of the basic and not infrequent reasons for disagreement between physician and patient on treatment issues is their divergent views on the goals of treatment. As goals change in the course of disease (e.g., a chronic neurologic condition worsens to the point of needing ventilator support, or a cancer that has become refractory to treatment), the physician must communicate with the patient in clear and straightforward language, without the use of medical jargon, and to define the goals of therapy under the changed circumstance. In doing so, the physician should be cognizant of patient factors that compromise decisional capacity, such as anxiety, fear, pain, lack of trust, and different beliefs and values that impair effective communication.

Money and Healthcare in the New Millennium

Scott B. Rae, PhD

The discussion of money and health care has been dominated in recent years by the phenomenon of managed care, how it has replaced traditional fee-for-service medicine, and the debate over the costs and benefits of such a system. Many physicians entering practice often come under various managed care payment plans, leaving them with limited knowledge of standard fee-for-service medicine. This will be increasingly true for the next generation of health care professionals.

At a fundamental level, the rise of managed care medicine, particularly for-profit managed care organizations, has raised a growing concern about the blend of business and medicine. Although there has been reluctant acceptance of managed care medicine by the general public, there is still widespread public skepticism about the ability of managed care organizations (MCOs) to serve the health interests of their customers when those interests conflict with the interests of their shareholders in maximizing their return on investment. Indeed, numerous bits of discouraging anecdotal evidence are now available, which have added to the public skepticism about this new intersection of business and medicine.

It is widely assumed in this discussion that two different sets of ethical standards are in fundamental conflict. The traditional medical ethic emphasizes patient well-being and autonomy and the physician’s obligation to the patient. This stands in conflict with the way business ethics is widely perceived as having its primary emphasis on profit maximization. Many assume that these two standards cannot be brought together and that managed care is a largely successful attempt to undercut the traditional medical ethic with a business ethic that is concerned only with the bottom line. Numerous observers have stated that at some level, obligations to the bottom line will directly conflict with duties to serve the needs of patients. Simply put, it is believed that there will be inevitable and irreconcilable conflicts in mixing business with medicine because the traditional “good” for medicine (dating back to the Hippocratic Oath) has been the health of the patient, while the “good” for business has been and continues to be profit.

To suggest that a business ethic is only concerned with profit maximization is to misunderstand what business ethics is about. A business “ethic” that espouses profit maximization as the sole goal of business is an oxymoron. However, the conduct of some HMOs around the country does reinforce the notion that all they are interested in is the pursuit of profit, at any price. The fact that some HMOs have been acting unethically in their pursuit of profit maximization is disconcerting.

Looking into the future of money and health care can be alarming. Still, it is important to take note of areas in which money and health care will continue to intermingle, raising significant ethical issues. Questions concerning the criteria by which health care is distributed – such as those based on need, merit, social worth, ability to pay, or some combination of these – are at the heart of the current discussion of health care reform. The door is open for theologians and philosophers to bring distributive justice reflections into the current health care debate.

Upon entering this debate, people first need to admit that the scarcity of resources for health care is absolute, not imagined. Second, they need to address the issue of whether health care should be viewed as a right, where people expect all they need without having to worry about paying for it, or a commodity. The traditional medical ethic has been to put the patient’s interests ahead of everything else and to seek the patient’s best interests irrespective of the costs involved. This ethic has implicitly assumed that medical resources are not an issue and that there are no interests at stake other than those of the individual patient. However, since managed care has brought the scarcity of resources to the forefront of society’s attention, physicians’ obligations have become divided. Physicians are now confronted daily with the prospect of conflict between the patient’s best medical interest and the physician’s/hospital’s financial interest. It seems clear that the fiduciary relationship between physician and patient demands that the physician put the patient’s interest ahead of his or her self-interest. However, the more difficult conflict raised by the scarcity of medical resources is the conflict between the interests of individual patients and the interests of the entire patient population being served by the physician/hospital. Whenever there is a fixed amount of resources available to treat a patient population, conflict between the interests of the patient population and the interests of individual patients is likely.

Third, people need to be able to recognize the point at which medical treatment is futile. Virtually every day in hospitals and medical centers around the country, families make inappropriate requests for aggressive treatment at the end of life. More often than not, physicians accommodate these requests out of a fear of being sued or to avoid tension in dealing with the family. The result is that resources are unnecessarily spent at the end of life on futile or burdensome treatments which are very expensive but offer, at best, only minimal benefit. In the vast majority of these cases, there is clear consensus that the best course of action for the patient is to stop aggressive treatment and initiate a regimen of palliative or hospice care instead.

Fourth, people should develop a knowledge of and expertise in business ethics. In the last 2-3 years, ethics committees increasingly have been asked to shift their focus from strictly clinical ethics issues to those that deal with the business side of health care, or organizational ethics. Those involved in ethical reflection in hospitals and medical centers will be asked to blend business ethics and medical ethics to formulate an ethic that benefits both patients and the organization serving them. It would be in the interests of those in the bioethics community to become more educated about the sister field of business ethics so that they may better serve their institutions.

Fifth, people must express their concern for those who are poor and who lack sufficient health insurance. Often, the most difficult issues in medical ethics have to do with access to care for the uninsured and underinsured. However, some people indeed lack adequate health care coverage as a matter of choice or just temporarily. In contrast, in between jobs, the majority of such persons feel vulnerable and would be very vulnerable indeed if faced with a serious illness.

Regardless of how the macro issues are resolved, an integral part of the health care system, particularly if the trend toward the market continues, will be the provision of care for the poor by charitable and religious groups. Christ’s admonition to care for the vulnerable surely applies to the poor, especially when they are experiencing serious illness and decline in health. Market forces should not be allowed to force physicians and hospitals away from providing charitable care. In the age of managed care, Christian health care providers – who follow in the tradition of the healing ministry of Christ – must take seriously the biblical mandate to care for the poor and ensure that such a commitment is evidenced in their practices.