Retainer Medicine,Social Justice and the importance of framing the debate

In the not too distant past, but well before the current generation of medical students and house officers were born, a person might go to a physician with some medical problem and be charged for the medical services and then pay for the service either out of pocket or out of pocket and then file with an insurer to get or all some of that reimbursed. It was a private transaction between two persons in a country in which private transaction between individuals was so normal as to not attract any attention. The ethics or justice of such a transaction was simply not a topic for discourse.

In the not too distant past, the ethics of the medical profession was generally well defined and could be expressed in a few simple sentences and seemed to be firmly imprinted in the physician's mind as part of the transition process from a lay person to a physician.
Respect for autonomy, beneficence, and non-maleficence. It was all about the physician and the patient-do no harm, act in the patient's best interest and respect the patient's views and wishes . It was a two party deal.

The AMA 2001 published version of the ethical principles is a bit more detailed but contained little to be contentious about and does not contain the word "justice". More on that latter.

Later, a fourth major principle was grafted on the the ethical framework-justice. In the beginning there could have been a bit of ambiguity as there are many definitions of justice. But it became quite clear what was mean by justice with the publication of the Medical Professionalism in the New Millennium.A Physician Charter.( Annals of Internal Medicine 5 Feb. 2002, vol 136 pg 243-246.

The justice of which they spoke was social justice. Thomas Sowell makes the distinction between the traditional American society's version of justice and social justice in this way. On the one hand, we have justice as basically applying the same rules and standards to everyone -equality of opportunity or equality under the law. On the other hand, we have the redressing of those inequalities that proponents characterize as the fault of society-equality of outcome. In the latter, whatever characteristics at issue are thought to be unequally "distributed" between various groups (income,medical care,access to swimming pools) should be "redistributed". Whatever may have been distributed by acts of God, accidents of history, an uncaring society , or whatever, to achieve social justice someone or something needs to correct the mal-distribution. When redistribution is needed, force or the threat of it is required.

Making everything right would appear to be quite a task to assign to busy, working in the trenches docs, so one should not be surprised by the results of a survey,that I talk about here, that indicated that concern for social justice does not take up a large amount of a physician's times or enter heavily into his daily clinical decisions and activities.

Not only it is quite a task, proponents of new professionalism tell us in August 2007 JAMA article that after "further reading" of the tenets of the new professionalism that physicians alone cannot do it. So who should do it? We are told it should be a medical societal alliance. My translation is that again we told medicine is far too important to be left to the individual patient and the individual physician and we need more powerful players, probably the government,likely big insurance and well connected medical academic intellectuals, such as those who write such articles to mobilize things and makes the inequities right.

Thomas Sowell writes about a "moralistic approach to public policy" in the concluding section of his book, "Knowledge and Decisions". I characterize the authors of the New Medical Professionalism with their insistence of physician's allegiance to social justice - in a society where there is no dominant secular view of justice at all-as medical moralists.

In Sowell's section entitled "Embattled Freedom" we read ...The desire for freedom and its opposite,power, are as universal as any human attributes....The moralistic approach to public policy is not merely a political advantage for those seeking concentration of power. Moralism in itself implies a concentration of power...The reach of national political power into every nook and cranny has proceed in step with campaigns for greater "social justice".

The recent, at-times heated,discussions (see here for some links) about the ethics of retainer practices illustrate how the concept of social justice as an alleged medical ethical imperative as promulgated by the medical moralists has framed the discussion and attempts to control the dialog.