The coruption of medical practice

Drs Hartzband and Groopman hit another major home run..See here .

This husband and wife physician team  from Harvard Medical School have published cogent thoughts before  regarding serious issues in  current day medical practice.See here for their critique of the concept of quality adjusted life year (QALY) and here .

They contend that  medical care is being corrupted by the actions of several groups-insurers,hospital networks and regulatory groups.I would add that philosophical (ethical ) cover is provided by health policy experts who are attempting to change medical ethics from one in which the  physician has a strong,primary fiduciary duty to her individual patient to one in which the physician is obligated to act in the alleged benefit of the group.This attempt is exemplified by the New Professionalism initiative which is spearheaded by the American College of Physicians (ACP) and the American Board of Internal Medicine (ABIM and its foundation (ABIMF) and the Robert Wood Johnson Foundation (RWJF). Additionally, the movement for a "Population Medicine " approach  depends heavily on this sea change in medical ethics.Simply put- the population medicine approach is dead in the water unless physicians reject their traditional fiduciary duty to their patient.

Quoting the authors from their NYT article:

" Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions.Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice."

and later

"When a patient asks “Is this treatment right for me?” the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole

We fear this approach can dangerously lead to “moral licensing”"

"Obsolete" is actually  the term  used by Dr. Harold Sox, former , long time editor of the Annals of Internal Medicine in his JAMA commentary  of  11/13/2013: I quote:

"Perhaps the de facto organizing principle for US health care approaching each patient strictly as an individual is obsolete.The population health approach is an alternative." [my bolding]

  

A NEJM opinion piece  by Victor  Fuchs carries further the theme of treating the collective. Quoting myself from an earlier posting:

In his closing paragraph, Fuchs tells us that when a physician works in a health care collective in which there is a fixed annual budget the physician resolves the dilemma [ the situation in which the cost effective option may not help or actually harm a given patient] by favoring the cost effective option. This according to Fuchs become "appropriate". ( Why does Fuchs use quotes marks?) So,the cost effective choice is the appropriate choice and also the ethical one. It is ethical in the moral calculus of Kant "because if all physicians act the same way,all patients benefit" .  Those comments by Fuchs are my candidate for the sophistry prize of the year in the health care category.

Does he really say that the medical ethical thing to do is to always choose the cost effective approach?Are there no other values worthy of consideration?In what sense does a patient deprived of care to further some alleged aggregate metric of a  group benefit?

addendum: 12/27/14.Minor spelling and punctuation corrections made and on 6/5/15