Dr. Doenges, past president of the Association of American Physicians and Surgeons, is engaged in Private Practice-General Surgery in Anderson,
No ethical physician would claim that he healed the patient’s wounds or made the patient well. None can do more than assist the natural processes. If the physician were the final authority, every patient would recover quickly and none would die. No physician can fail to realize his personal limitations. He must admit the existence of a Greater Power. No other profession renders services in this intimate area in which the individual faces life and death. This brings the physician into a more intimate relationship with the patient than exists between the same individual and any other professional person. Complete mutual understanding and confidence is essential and seldom exists outside this area of intimate contact.
The best interest of the patient requires that the individual patient-physician relationship be held inviolate in every area. This includes every contact between the patient and his physician, whether it involves the history, examination, and treatment, or the area of compensation for services.
Highest quality medical care cannot exist if the traditional moral and ethical concepts of medical practice are violated. The key to good diagnosis is good, honest, and complete history. The knowledge that information confided to the physician will not be divulged to others permits even the most timid patient to give the most personal, intimate, and confidential information to his physician. Consultants are frequently denied this same information which is freely given to the patient’s "own" doctor.
For thousands of years physicians have fought for the right to hold inviolate from all probers and other curious individuals facts elicited in the medical history and examination. These rights of privileged communication, granted and enforced by courts of justice, are essential for successful treatment.
In the final analysis only two individuals are involved in medical care: the patient, who has chosen the physician to whom he will entrust his care and actually his life, and his physician, who has freely agreed to provide such care. (Due consideration is given to those individuals for whom another acts "in loco parentis.") No other person, no "third party," is required. When any "third party" enters the picture, he is an intruder and can only reduce the uninhibited rapport and confidence which must exist between patient and physician.
All are acquainted with the numerous difficulties and objections reported regarding the operation of "third party" National Health Insurance schemes, such as the "red tape," the innumerable form which costs with the associated tax increases, the increasing demands for nonessential services and supplies, the abuses which defy elimination, the ever-increasing waiting lists for hospital admissions, the unreasonable delays in every area, the decreasing hospital services, the dissatisfaction among patients, hospital personnel, and physicians, as well as the wasteful operation and other evils to which every bureaucracy is heir. Bureaucratic systems are not confined to governmental agencies. They can and do exist in most businesses, labor unions, and some medical organizations.
These facts alone provide sufficient concrete reasons why government, and other "third party" "health programs" via "insurance" or "service" plans, historically result in less satisfactory and inferior quality medical care.
Quality of Service Suffers
However, there are other and more important factors which make it impossible for medical care supplied through "third party" programs to equal or even approach the quality of medical care supplied through private practice operating under the market economy.
An essential feature of quality medical practice is that the patient is and must be regarded as an individual—a moral being. Individuality is the very basis of the practice of medicine. All medical tradition emphasizes the fact that every patient is an individual, that his ills are singular, and that he must be so regarded and treated. Health and disease are strictly personal matters.
Personal responsibility, upon which all freedom depends, is another basic essential in the successful practice of medicine. It applies to the patient as well as to the physician.
The patient’s responsibility cannot be eliminated or violated. If he withholds information or misrepresents facts to his physician, he removes one of the basic requirements for good care. He ties the physician’s hands. If the physician does not share the confidence of his patient, he cannot treat the patient adequately or properly and his chances of helping are greatly reduced. If the physician disregards the facts, the patient suffers. Medical care is not a mechanical f unction!
How Choice Is Limited
"Third party" medical care always results in control of the patient and the physician by limiting the free choice of the patient in selecting his physician and by interfering with the individual patient-physician relationship. Physicians are frequently classified, not according to ability, but on an arbitrary and unrealistic basis such as membership in certain organizations or other interesting but relatively unimportant details. Experience, results, ability, confidence of patients, and personal interest are relegated to a minor position. Physicians are rated by "third party" agencies as to the type of practice they may perform and the type of disorder they may treat.
Freedom of choice is further limited because the services which may be rendered by any classification are controlled and regulated by the "third party."
Under "third party" control, physicians are paid according to classification regardless of whether it is on a fee for services, per capita, panel, hourly, or salary basis. All "third party" programs eventually utilize the principle of "fixed fees."
Physicians who participate in such schemes must agree to render totally unknown and unpredictable quantities of service for a predetermined fee. The "taxpayer" is promised by politicians or "third party" officials that physicians will deliver any and all services for a fee set by the "third party." In the final analysis, the "third party" always establishes the fee to its satisfaction! This procedure inevitably and obviously places the emphasis on the quantity of medical care and relegates quality to a position of secondary importance.
No One Is Responsible
Under any system of "third party" medical programs the patient must accept the "third party" into the patient-physician relationship in every area, not in the area of fees alone.
The physician is required to accept the "third party" by reporting or certifying illness to someone other than the patient himself. This begins the deterioration of and destruction of the confidential nature of the patient-physician relationship.
The patient feels justified in relinquishing his responsibility in return for the "third party’s" payment of fees. The physician also begins to look to the "third party" in this area of responsibility and justifies his attitude by the requirement of supplying the "third party" with information. The physician even begins to hold the "third party" responsible for what he regards as the "proper" use of the funds removed from the patient not infrequently by force, by dues, royalties, taxes, or other means.
These practices encourage the patient to divorce himself from his sense of personal responsibility to his physician in the area of fees. Having accepted the idea that someone else may rightly assume his responsibility, it becomes a matter of indifference to the patient, and eventually to the physician, who assumes this responsibility.
At the point where the physician accepts such an agreement, he joins his patient in flight from personal responsibility and accepts the idea that a "third party" is responsible for the payment of the patient’s bills, and in so doing, grants to the "third party" the right to establish his fees and the category in which he may function.
Destroying the Market Economy
The attempt to establish "third party" medical programs is a definite attempt to destroy the market economy.
Any argument in favor of "third party" medical programs may be used, by changing a few words, with equal validity to promote "third party" control of every other profession; every other need and desire; in short, of every segment of the economy.
Highest quality medical care cannot survive under any system in which there is "third party" interference. This has been and will be true, always, regardless of the promises of politicians or businessmen, the misrepresentations of labor union leaders, or the compromises of some in the medical profession.
Remember one thing: Only doctors can deliver medical services. Only individuals trained and experienced in the healing arts can fill the medical needs of the people of this nation.
Our obligation and responsibility is to the individual patient. All agreements must be with each individual patient!
We should never refuse to deliver services to our patients but those services should be delivered to individuals as our own private patients, not as wards of the government, a union, any insurance company, or any other "third party."
Some scheme of compulsory sickness insurance [on the German pattern] exists in every European country except Switzerland where the government subsidizes the medical cooperatives. The costs are rising relentlessly, but nowhere as fast as in Britain. And nowhere was the insurance principle so completely perverted into a communistic practice as in Britain.
Aneurin Bevan launched in 1948 the new health service that was to provide care in accordance with Lenin’s rule: Everything free of charge to everyone irrespective of means. The Bolshevists never put the idea really into operation; the British are finding out that they have caught the proverbial bear by the tail.
The experiment turned out to be much too expensive. The demand responded to zero price. In nine years, British retail prices increased by about 40 per cent, the cost of governmental doctoring more than trebled. It amounts to more than 10 per cent of the over inflated national budget, not counting the cash payments by the "insured" or the municipal contributions.
What the zealous socialist could not foresee did happen: Something for nothing is extremely popular. Virtually the whole population, millionaires and foreign visitors included, signed up. Aspirin was distributed "by the ton," enhancing the Treasury’s headaches.
To 40 million people of England and Wales alone, 609 million prescriptions, 191/2 million pairs of glasses, 7 million dentures, 700,000 appliances of "main types," and 130,000 hearing aids were dispensed in less than three years.
The only check on the demand was the fact that the supplies ran out.
Nationalizations—Ten Years Later
1Tor the purpose of this discussion, the "third party" is defined as: any individual, agent, or agency, through whose control of persons or control and/or administration of funds belonging to or assignable to the patient (or for his care), occupies a position capable of affecting the patient’s choice of a physician to provide medical care for himself and others for whose care he is legally and/ or morally responsible, or of affecting the freedom of the unrestricted bilateral patient-physician relationship.
This discussion does not include consideration of those special cases such as individuals in prisons, in military service, and the like, and the very special situation wherein industry is required by law to assume the position of "parent" in cases under workman’s compensation laws, which require more time than the patient receives, the sky-rocketing.