Physician fiduciary duty-a thing of the past?

Has the increasing hegemony of third party payers over physicians lead to a change in medical ethics, one that is compatible with and may even serve to justify a collective approach to medicine.

Until it was deleted in 2003 by the ACGME, Resident Review Committee (RRC) for Internal Medicine, the following statement was a touchstone of IM training and future practice ;

"Physicians...must recognize their obligation to patients are not discharged at any given hour or any particular day of the week.In no case should the resident go off-duty until the proper care and welfare of the patient is ensured".

It has been suggested that the most significant change in post graduate medical education occurred in 2003 when the ACGME instituted rules limiting house office duty hours. I suggest at least in regard to internal medicine the above omission signaled a more significant change.

However, I believe a broader change occurred with the publication of the "New Professionalism" In this, physicians are charged with more than care of their patients they are somehow to serve as stewards for the collective medical resources.

The New Professionalism speaks of three fundamental principles

Primacy of patient welfare. Here they got off to a very good start and one that apears to be without conflict with the (unstated) "old Professionalism".

Principle of Patient Autonomy

Principle of Social Justice. Here physicians are urged to promote " justice in health care including the fair distribution of health care resources".

In the first two principles the issue is simply ( simple in theory not in practice) to do the best thing for the patient. The locus of concern is the patient. Fidelity to his/her welfare , to act in the interest of the patient are the goals of the physician. In the third- problems arise, however.

"Justice" is a term with multiple meanings and interpretations but the authors of the new professionalism seem to specify a certain type of justice, namely "social justice". However, even the term social justice is not without different meanings and interpretations. Libertarians would argue that social justice in one of its more common interpretations violates the principle of "non-aggression". Social justice advocates commonly argue for equality of results versus the libertarian view of equality of opportunity and equality under the law and for legislative actions to bring about those allegedly fair outcomes.

Similarly what one considers as fair is determined in part by what concept of justice one has.

The arguments and related philosophical considerations could take up volumes but my point here is simply that the terms social justice and fairness do not mean the same to everyone and there is no reason that a small of physicians ( the authors of the "New Professionalism") should preemptly settle those arguments and disagreements by declaring what philosophical stance is appropriate for the physician as she practices medicine.

Critics of the new professionalism argue that the first and third principles stand in contradiction to each other. Proponents counter simply that there is no contradiction. This is much like the arguments that goes "health care is a right" "- No it is not." Debate will not settle polar opposite views .

I believe that principle number three justifies a collectivist approach to medicine and if one follows the "follow the money rule of thumb" the new professionalism could serve well as a philosophical cover for the "movement" that claims that the solution to all of American medicine's problems are medical collectives in which the greater health good can be achieved. Physicians who are locked into the fiduciary model would not be eager participants in this new world and the philosophical trial balloons for a utilitarian alternative have been floating for some time.