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.