Compared to most others in society, physicians endorse, and are held to, higher ethical standards. (To illustrate, here are ethical codes from the AMA and the World Medical Association.)
High standards apply to professionals in other fields as well, especially fiduciaries such as attorneys, accountants, school teachers, and judges. But standards of medical ethics may be among the most stringent. We put patient welfare first, and anything that interferes with this primary aim is deemed a conflict of interest (COI). For example, it is legitimate to make money as a physician, i.e., to earn a living, but not in any way that detracts from patient welfare. These are not black and white distinctions, however, and line-drawing controversies abound.
Offering unneeded treatment is always unethical. But what about limiting one’s practice in lucrative or otherwise pleasant ways: orthopedic surgeons practicing in ski towns, plastic surgeons who only do cosmetic surgery? What about choosing a more lucrative specialty in the first place? Accepting only certain types of insurance, or none at all? Charging for missed or late-cancelled sessions? Without attempting to resolve any of these examples here, it’s noteworthy how much concern is voiced, and ink spilled, over how physicians practice. To completely escape controversy, we’d have to take a vow of poverty and offer our services for free.
In contrast, many other businesses that affect health do not share the physician’s ethics. Precise line-drawing plainly doesn’t apply. Beverage companies peddle diabetes along with refreshment, supplements come adorned with dubious health claims. Snack food can be unhealthy. Manufacturers and retailers of exercise equipment need not refer customers to more suitable products from competitors. One can even argue that new cars, not to mention video games, movies, and many other products, discourage people from exercising. “Patient welfare” simply isn’t a priority for most firms — they aren’t dealing with patients. There is no general code of business ethics that makes health its primary aim. Thus, in extreme cases the government — we the people — step in, by limiting tobacco and alcohol ads for example, or by inspecting meat. This is one reason we have government: To set priorities that an ungoverned free market cannot or will not.
Some firms do explicitly deal with patients, yet still do not share the physician’s ethical standards. Insurance companies run feel-good ads that obscure their cost-containment mandate. Medical corporations attract customers or subscribers who are “covered lives” as opposed to individual patients. Pharmaceutical companies entice the public with all the irrational tricks used to sell other products, then tack on “ask your doctor” to absolve themselves of any medical responsibility.
Pharmacy benefit managers (PBMs) can disallow a physician’s prescription wholly on the basis of cost, and without taking medical responsibility. These are all huge “conflicts of interest” from a physician’s point of view. But COI doesn’t apply the same way to entities with less stringent professional ethics, where the primary aim is profit, not health.
This makes our burden harder. For the most part, it isn’t up to pharmaceutical companies to avoid biasing doctors with their promotional efforts. It’s up to us. Moreover, it’s up to us to counter unhealthy biases instilled in the public, like the willingness to use an antipsychotic with significant side-effects to treat routine depression. Likewise, as long as insurers and PBMs are corporations, no one will compel them through moral persuasion or ethical codes to sideline their economic interests. It’s not a conflict for a business to maximize return for its shareholders; it’s the main reason they exist. Indeed, too much concern for patient welfare might be criticized, e.g., at a shareholder meeting, as a COI that impedes this primary aim.
Doctors are held to standards that would be absurd in virtually any other business. Historically, these higher ethical standards gave us a special status in society, and earned our patients’ trust. The erosion of this special status, and of patient trust, is both a cause and an effect of a health care environment with lower, more businesslike, ethical standards.
The accelerating corporatization of American medicine replaces traditional medical ethics with the looser standard of business ethics. MD decisions are now vetoed by MBAs. As a result, patients may see us as replaceable technicians in a corporate infrastructure, and lose the benefits of a personal physician. In parallel, physicians who are viewed by their patients and employers as mere cogs in the wheel of a large system are more apt to relax their own high ethical standards. I fear for both our profession and the public as this vicious cycle continues.
While we doctors are busy maintaining our ethics and watching out for COI, other “stakeholders” in health care operate under fewer ethical constraints and enjoy greater profits, often directly at our expense. It can be maddening, yet physicians have no unified voice to defend ourselves and our work. Proposed solutions are inescapably political, and polarize us along deeply divided political lines, left versus right. Ultimately, though, traditional medical ethics and public welfare are on the same side. Doctors exist to help individual patients — and we will all be individual patients someday. The monumental challenge is whether we can put our internecine struggles aside long enough to save ourselves, our families, and our neighbors.
Steven Reidbord is a psychiatrist who blogs at Reidbord’s Reflections.
