Dr. Singer practices medicine in Phoenix, Arizona.
Govemment health-care reform is like Frankenstein’s Monster: dead, it seems, but threatening to arise from the grave, regenerated by countless, often contradictory parts. Like the Monster’s creator, our politicians and health-care bureaucrats—eager to create something—often give short shrift to ethical considerations. This failing is the focus of my essay.
While medical ethicists disagree on a number of issues, there are certain principles nearly all share. Whether or not we intend to adhere to these principles is the question we must answer.
The Hippocratic Ethic
One conflict that must be resolved is the choice between remaining committed to the “Hippocratic Ethic” or embracing what is called the “Veterinary Ethic.” The Hippocratic Ethic holds that a physician’s ultimate responsibility is to the patient. Consequently, all advice given regarding therapy is based upon what the physician perceives to be in the patient’s best interest. The Veterinary Ethic holds that the physician’s ultimate responsibility is to the payer, and that advice is therefore based upon what the physician perceives to be in the payer’s best interest. An example of this is when the veterinarian recommends to an owner that an animal be “put to sleep” rather than undergo costly treatment.
As our health-care system is reformed, we risk abandoning the Hippocratic Ethic in favor of the Veterinary Ethic. If the system pushes more and more of us into a “managed-care” setting, where the physician is under the management of insurance company administrators who ultimately answer to government regulators, the physician will be put in the position of conforming to a method of practice where the interests of the payer are paramount.
Similarly, if our system is changed to a single-payer” type of health-care system, the physician will be under the management of government bureaucrats, who in turn are influenced by budgetary constraints and pressure from special interest groups. The doctor will be forced to comply with practice guidelines set up by the government. Again, the interests of the payer prevail.
The issue of patient autonomy is also important. A fundamental precept of prevailing medical ethics is that patients who are conscious and mentally competent should have control over their bodies in medical decisions. Put another way, nothing should be done to the patient without the patient’s “informed consent.”
To this end, medical schools and teaching hospitals have institutional review boards to oversee research on patients. These boards insist that researchers develop informed consent documents which explain, in layman’s terms, the reason for the research, what the researcher predicts the patient to experience and gain, and what the researcher hopes to learn or accomplish by the experiment. Implicit in this policy is the belief that it is possible to make this information clear and understandable to nonphysicians, and that most patients can make a reasonably informed decision about whether to consent, even in the case of a complex and esoteric procedure.
When patients are moved into a situation where their doctor must answer to an overseer, they lose the ability to give “informed consent.” The doctor must follow regulatory guidelines when ordering tests or recommending procedures, and can only prescribe medications that are listed in a formulary. Is the patient ever aware of other options that could have been considered, even if they were more expensive?
When a doctor prescribes a drug in the formulary, is the patient aware of other drugs that could have been prescribed, and their relative risks and benefits as well as their relative prices? Is the generic drug always as good as the brand-name drug? Is there a more expensive alternative form of treatment that does not involve the use of drugs and yields quicker results that is not being brought to the patient’s attention? These questions apply whether we place the patient in a “managed-care” system or a Canadian-style “single-payer” system.
When people are placed on prioritized waiting lists for surgical or diagnostic procedures, they are not fully informed about the risks being taken with their lives by being forced to wait. The ultimate power for decision-making is in the hands of a healthcare bureaucracy that determines how much money will be allocated for each problem, and in some cases, to each health-care facility. People may be given a degree of choice regarding who their doctor will be, but they are allowed to make very few choices about what type of health care they receive. In most cases they are kept completely in the dark regarding the various options that exist. This is because a third party—government or “managed-care provider”—controls the money.
While it is reasonable and appropriate to consider these ethical issues when determining how we intend to transform the existing health-care system, it is important to realize that the time-honored ethical precepts discussed above are already ignored. Over the past several years, policy-makers and health-care providers have begun to change the way in which health care is delivered with complete disregard for medical ethics. In many cases the individual doctor unconsciously violates his ethical credo on a daily basis. As a clinician in private practice, I make this statement based on firsthand observations.
Medicare and Medicaid
Consider first the 40 percent of Americans who are on either Medicare or Medicaid, single-payer types of health-care delivery arrangements. The patient pays little or nothing out of pocket for health-care expenditures. The government is the payer.
Over the years, in order to control Medicare and Medicaid expenditures, the government has begun to manage the way health care is delivered. One way in which it has done this is by changing the way in which it reimburses hospitals for services. Rather than reimbursing on a fee-for-service basis, it does so on the basis of Diagnosis Related Groups (DRG’s). The hospital is reimbursed on a flat rate pegged to the patient’s diagnosis, regardless of the severity of the illness or the amount of hospital-based services a particular patient requires.
In order to reduce losses, hospital staff-utilization review committees have resorted to intimidating and pressuring physicians to treat certain problems ordinarily handled in the hospital on an outpatient basis. They are also pressured to discharge patients sooner than they would ordinarily recommend. If doctors are found to be “poor utilizers” of hospital resources from a cost-effectiveness perspective, they often must go to great lengths to defend their actions before peer review committees or else face sanctions. Most doctors don’t have the time or inclination to face such hassles. For this reason, most physicians find themselves taking certain risks with their patient’s health that go against their better judgment, rationalizing that they are following the prevailing “standard of care” in making their decisions.
Also in the interest of controlling costs, hospitals have gone to a formulary system for dispensing medicines. A Pharmacy and Therapeutics Committee determines what drugs will be available in that institution. If a doctor wishes to place his patient on a medication, he can select only from the medications in the formulary, a catalog of drugs that the Committee decided should be available to doctors practicing in that hospital. If the doctor wants to prescribe Antibiotic “A” for his patient, but this drug is not in the formulary, he has to select his second-best (or third-best) choice. Otherwise, the doctor has to go through a maze of procedures in order to get special authorization to order Antibiotic “A.” (The Pharmacy and Therapeutics Committee determines by consensus vote of its members which drugs to place on the formulary, cost being the overriding concern. This formulary affects all hospitalized patients, not just those on Medicare, since the hospital is trying to recoup its losses from operating under he DRG system.) In most cases, the doctor just decides to “go with the flow” rather than take the time to fight for what he sees as the patient’s best interest. Again, he finds solace in the rationalization that a hospital committee has made this practice the “standard of care.”
Leaving the hospital setting, doctors are under constant pressure to see patients in their offices for a particular illness at a frequency prescribed by Medicare or Medicaid. If they see these patients more often than Medicare or Medicaid “allows” they are not reimbursed for their service. They must choose between practicing medicine that’s not in their patient’s best interest, or facing financial loss. Oftentimes they opt to follow the Medicare- or Medicaid-prescribed guideline, rationalizing that the fact this is prescribed by a government agency makes it the “standard of care.”
The same can be said for the ordering of certain diagnostic screening tests. From chest x-rays, to mammograms, from cardiograms to prostate-specific antigen (PSA) tests, the proper frequency and indications for ordering these tests are determined by a government bureaucracy. If doctors don’t follow these guidelines, they don’t get paid. What’s worse is that they run the risk of being excluded from Medicare or Medicaid if they become identified as “problems.” In most cases, doctors simply acquiesce.
Of the remainder of the population not on Medicare or Medicaid, roughly 90 percent receive employer-provided low-deductible health insurance. Few health-care costs are paid out of pocket by the patient. The insurance company pays most of the bills, and passes the cost on to the employer in the form of premiums. In an effort to hold down rising premiums employers have resorted to placing their employees in “managed-care” plans. Today, if we include Health Maintenance Organizations (HMO’s), Preferred Provider Organizations (PPO’s), or regular fee-for-service plans that have “utilization review” and “pre-certification, 9′ more than 90 percent of the non-Medicare/Medicaid population is in “managed care.”
In the managed-care setting the same pressures on the physician exist as in the Medicare/Medicaid single-payer system. The doctor must get authorization from an overseeing entity in order to order tests and diagnostic procedures, perform surgeries, or prescribe medications not in the managed-care company’s formulary. The doctor must get permission to place a patient in the hospital. In many cases, the doctor must get permission to refer a patient to a specialist. The criteria used by the oversight entity granting permission are closely linked to the issue of cost. Whenever there exists a diversity of opinion in the medical literature regarding the proper management of a particular medical problem, it enables the managed-care company to seek refuge behind a credible source in defending its policy medico-legally. The overseeing entity will then tend to only allow the least expensive approach to be authorized. These criteria can be overruled if the doctor is willing to jump through enough bureaucratic hops to get special permission. Of course, if he does this too often he becomes too expensive for the insurance company to maintain on contract. It might terminate the doctor. Consequently, most doctors tend to comply.
It should come as no surprise that, according to the National Ambulatory Medical Care Survey, managed-care programs are less likely to authorize expensive diagnostic tests. For MRI and CT Scans the difference is a factor of two to one. As a consequence, patients with diseases such as cancer are likely to have their conditions detected at a later stage, making treatment more difficult.
Studies by Mark Schlesinger and David Mechanic (Health Affairs Supplement, 1993) conclude that although managed-care and traditional fee-for-service plans tend to adopt the same method of treatment where normal practice guidelines are well-defined, where norms are vague the prepaid plans provide significantly diminished levels of treatment.
As an adjunct to their own oversight entities, many HMOs use the primary care physician in the capacity of “gatekeeper.” Many of the decisions regarding appropriateness of referrals to specialists, or regarding authorization of procedures or tests recommended by these specialists, are placed in their hands. The primary care physician is financially penalized for expenditure outlays by the managed-care program and rewarded for expenditure savings. This again places him in the bind of having to choose between the interests of the patient and possible financial ruin.
New Medical Ethics
In all of the above examples, the physician is implicitly forsaking the Hippocratic Ethic. He is making decisions based upon what is in the payer’s best interests. All of these decisions are being made without the patient having informed consent. The patient is never aware of what other options existed with respect to tests being done, medicines being prescribed, procedures being performed or not performed, or specialists being consulted.
As Merrill Matthews has said, “In effect, medical ethics has succumbed to medical economics, as paternalism is given precedence over autonomy.”
A recent well-known victim of the new medical ethics is former Secretary of Defense Les Aspin. He needed additional vaccinations because of the travel requirements of his job. His doctors gave him a vaccine slightly more risky than one which would have cost $1.55 more. Secretary Aspin was hospitalized in an Intensive Care Unit as a result. Did anyone ask him if he was willing to pay an additional $1.55 out of pocket to avoid the risk? Was he even aware such an option existed?
When Senator Bob Dole opted for a prostate-specific antigen test (PSA) in 1991, it led to a biopsy that detected early prostate cancer, and then an operation which the Senator believes saved his life. Most managed-care plans don’t see much benefit in this blood test and therefore don’t routinely provide it. Fortunately, Senator Dole had the opportunity to make his own decision.
This ethical dilemma need not exist. Doctors need not confront the choice between the Hippocratic Ethic and the Veterinary Ethic. If the patient were again the primary payer, there would be no conflict of interest between the patient and the payer.
If the patient had control of the money, the burden would be on the doctor to get “informed consent,” and to give advice in accordance with the Hippocratic Ethic. The patient would settle for nothing less.
But as long as politicians in Washington continue to show a blatant disregard for the ethical consequences of their policies, they will not avoid creating a health-care monster with a tragic destiny.