Wednesday, August 08, 2007

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.

3 comments:

james gaulte said...

Note: I re-posted this piece because I plan to reference it in a commentary about a JAMA article dealing with a "medical-societal alliance" and I noted a error in my original post in which I failed to list the second of the "new" professionalism's principles correctly as "Principle of patient autonomy"

DrRich said...

You are absolutely right.

Doctors are supposed to be responsible for their individual patients, and CANNOT be responsible for the equitable distributiion of society's resources (even if they wanted to; even if professional societies exhort them to). So why, under this new "official" ethical standard (which should have raised a great hue and cry when it was adopted but never did), are doctors now being urged to work for the "fair distribution of healthcare resources," based on "wise and cost-effective management of limited resources?"

There's nothing wrong with working for social justice, of course. Social justice is very important. Even doctors should care about it. But when they are seeing a patient who has come to them for help, that patient - and not social justice - should be their primary concern. They should not cheat or lie for that patient, not even to rapacious insurance companies. But within the rules of engagement (rules to which the patient, in one form or another, has signed up for) they should leave no stone unturned to see that the patient gets whatever medical services that might benefit him or her. Doctors should not be placed in the position of having to "fairly distribute limited healthcare resources;" of having to decide which patients are worthy of being offered available services and which are not; of having to weigh the needs of society against the needs of their individual patient and decide, on a case by case basis, which is to predominate; of having to ration at the bedside. But this is precisely what the new professional ethical standards provide for. For the first time, doctors have been given explicit ethical cover for covertly rationing healthcare.

One suspects that these new ethical standards were made necessary by the reality of the situation. Doctors cannot, under the covert rationing imposed on them by insurance companies and the feds, fully advocate for their individual patients anymore. They've got to keep the entities happy which control their professional viability (i.e., those insurance companies and those feds). But this makes doctors feel guilty, since their time-honored ethical precepts require them to place their patients first. The answer is simple.

If you cannot live by your ethical standards, change them.

Now, when doctors find themselves holding back from a patient because they've got to keep their true masters at bay, they can tell themselves, "Sure I'm violating Principle 1, but I've got to do that to meet Principle 3." If doctors can avoid too much introspection and self-analysis (which should not be a problem for many of us) this new precept may take away some sense of guilt. But in truth, as long as doctors are silently withholding care from patients who need it, without telling them and perhaps without telling themselves, no new revision of ethical principles can rescue them.

DrRich
GUTHealthcare.com

rlbates said...

Good post. I too believe that health care is not a right. Each individual should "be responsible for their own health", be good stewards of their own body, etc. We, physicians (& other health care workers) should do our best to help the individual achieve or keep good health, but if the individual has "patient autonomy" then they are ultimately responsible. I am responsible for providing the best knowledge and skill I can (often this is not "perfect").