Tuesday, October 16, 2012

21st Century Medical Ethics.

I was discussing physician's responsibilities with some young doctors today, and started to appreciate that there is a great divide between myself and them when it comes to a central question in medical ethics. This question concerns whether the doctor should feel that his primary responsibility is to the patient in front of him, or to the community. When it comes to lawyers, this question has a clear answer: the responsibility is to protect your client.  When a lawyer betrays his client's trust and reveals client's secrets to others, that lawyer is disbarred.  In medicine, the answer used to be the same: that is, a doctor's first and foremost responsibility is to the patient in front of him. However, every one of my young colleagues thought that our main responsibility is to protect the community.  That seemed like such a foreign concept to me.

From a business perspective, if someone pays you for a service, you must honor that agreement. Therefore, if a patient pays a doctor a set fee to provide a service and that doctor accepts this fee, it seems ridiculous if the said doctor would then tell the patient that due to shortage of resources the service can no longer be performed.  If the deal is broken, at the very least, the payment must be returned and the other person compensated in some way for all the trouble.  Good luck on trying to obtain services through Medicare in 10 years.

We also talked about what I would want if a stroke left me incapacitated and I was no longer able to communicate, had to be fed through a tube, and breathe with the assistance of a mechanical ventilator. I said that if I could still observe my loved ones growing up, that this would be enough of a reason for me to continue to live. They seemed shocked.  To them it was a clear waste of precious resources.

I explained further that after many years of paying into a medical insurance system and not having utilized it one bit, I would not feel any remorse if such a scenario that I described above would mean that I would then withdraw all these deposited sums and have expensive medical services used on myself.  This was not an ethical dilemma for me.  It was a simple business transaction during which I payed into an insurance plan and then being able to utilize this plan if a need should arise.

So why do my colleagues see this so differently?

There answer has a great deal to do with money.  One thing that has changed from the time that I entered medicine is that the relationship between a doctor and a patient in which the patient pays for the doctor's service is no longer the standard.  Now it is far more likely that this payment comes from some form of government, be it city, state, or federal.  If the primary payer is the government, then the doctor must honor this payer's wishes.  Also, many of the patients I now treat have not contributed anything towards their treatment but demand a great deal. They often lie to obtain disability and home aid services. Sometimes they lie to get medications, that they later sell. It then becomes understandable to see such people primarily as burdens on the rest of us.

What will happen when the role of a fee for service physician is phased out and only a single payer-government medical service remains? The doctor will be an agent of the government and the doctor's sole responsibility will be to enforce government policies.  To me, this sounds terrible.

One of the selling points of a government run health care system is that it would make medical care less expensive.  There are voices calling for setting limits to physician salaries.

In the end however, this may not turn out as such a rotten deal for doctors.  There is an old story about a Greek physician by the name of Melampus. In that story, the king of Argos asks Melampus to cure his 3 daughters from an acute case of acquired insanity. Melampus asks for half the kindom as payment and the kings tells him to get lost. Later, when all the women of Argos become striken with insanity the king asks Melampus for help again, and this time he agrees to a payment of his entire kingdom and for his daughters to marry Melampus and his brother.

The moral of that ancient tale is: pay the doctor his fee, or else you will later pay twice as much. All  those who believe that American medicine is too expensive and that if only we could control doctors' salaries by making these doctors work for the government might wake up one day to realize that their doctor has taken control of their government.  What if you should become a burden to this new government?

To return to the question of ethics, we are all better off with the patient-doctor relationship being based on a small business model. That is something that we can all live with.


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Sildenafil Citrate said...

We also talked about what I would want if a stroke left me incapacitated and I was no longer able to communicate, had to be fed through a tube, and breathe with the assistance of a mechanical ventilator. I said that if I could still observe my loved ones growing up, that this would be enough of a reason for me to continue to live.

GW said...

Fascinating window into the world of medical ethics, politics and economics. Thx Vinny.

Ex-Dissident said...

Thanks GW. I thought some more on this change I observed in my colleagues, and I believe that another reason is that we have become much poorer as a country.

Anonymous said...

I wrote a long comment but Blogger rejected it.
In a few words: I, too, think that Doctors' fees are too high. As well as insurance Cos' fees, labs' fees and cost of hospital stay. But the solution to these problems not government assistance and MORE SOCIALISM; quite the opposite - a good old tried-n-true practice of enhanced competition and increased market supply. As it is now, I have no insurance and a simple annual mammogram cost me an outrageous $700 - counting mandatory visit to the GYN to obtain a prescription, etc.
And I know I wouldn't be able to afford treatments if I get seriously ill. So I live in uncertainty and fear...very uncivilized, in the most civilized country on Earth. I am sure, I am not the only one in this situation.

Ex-Dissident said...

As things stand now, I think that buying insurance is not worth it. Most people buy into these high deductible insurance scams and their medical costs will never get higher than their deductibles. If they were to get seriously ill, then any of the current American hospitals will treat them fully and then they can simply ignore the bills. In the worst case, they can declare bankruptcy.

Anonymous said...

well, of all people you should know that "seriously ill" is not necessarily breaking a leg or something similar that just requires one visit to ER.
"seriously ill" means chronic disease - heart, endochrinological or oncological condition that require continuous and expensive treatment.

and even speaking of breaking a leg - what one to do after the surgery? no hospital will do prolonged outpatient post-operatic care, let alone private practices.

Besides, why take extreme case of bankruptcy? Current situation I ma in - and hundreds of thousands, if not millions people are, too - concerns not the extremely poor but mainstream lower middle class. People who do not own business but working for a boss who does not supply insurance - why should they suffer from insane fees charged by the medical professionals? They do everything right -they work, they save what's left from their market-defined salaries, they feed their children and pay their bills. Every simple visit to medical office cost one a week's paycheck - you think it's normal?
You and the rest of us, as professionals, are not that far apart, experience and education-wise. Why, then, medical professionalism receive 3 times on average for their service than a licensed engineer, architect or IT specialist?

Artificially-created shortage and expense, that's what I think.

Ex-Dissident said...

I think a visit to a doctor will cost you about the same as it costs to get your hair done. That is if you have no insurance and many clinics will do an adjusted fee. Anyway, I work in a hospital and have no control over what someone is charged. My close friend runs a private clinic in another state. He takes no insurances and charges 100 dollars per visit. More if it is a very involved first time visit. Is that your definition of an insane fee?

Anonymous said...

Read my 1st comment again, please. Insane fee - is when a simple, no-complications annual mammogram visit amounts to $700.
Because the racket works like a Swiss clock: radiology will not perform the procedure w/o doctor's prescription; doctor will not just leave that piece of paper @ his receptionist - oh no, they want to feel important, they make to visit for "annual check-up", and then charge accordingly (in my case, $275), then they send tests oyu didn't need to a lab (+$180), then the hospital's radiology charges "discounted rate" for cash patients - the remainder of $700. Is that what it should cost?

And that's just one simple monitoring act; what god forbid if more tests, more care and more visits would be needed?

One visit to your friend's clinic might cost $100 (for s 1st consultation!), but your friend does not guarantee to cure a patient in one visit, does (s)he? What other services, connected to this visit, the patient is required to pay for? I am talking just doctors; it's the whole thieving bastard of medical industry, complete with arrogant receptionists and rude nurses. And what other professional would charge his customer for being late or cancelling appointment? Especially when the same standard is not applied to him?

My hair dresser charges $75 - and she does what she promised in 2hrs. No doctor can even come close.