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Wednesday, September 04, 2019

Why would physicians advocate replacing Hippocratic medicine with Platonic Medicine?

The notion of a fiduciary duty of the physician to his patient is long standing . In the era in which I grew up medically  ( now over fifty years ago) the idea that a physician should be obligated to care for the group of which his patient is a member was not talked about.

I first read about the Platonic notion of the physician as one obligated to provide the best care for a group as opposed to an individual in a series of articles in the Journal of the American Medical Association (JAMA). I make no claim that this was the earliest advocacy but only the first of which I became aware.

A series of articles was published  in 1995 authored by Dr. David Eddy that championed the  merits of decision analysis which he hailed to be a mechanism to increase the quality of medical care while reducing costs. Eddy defined quality as the greatest medical good for the greatest number within some economic medical collective. Eddy discussed the merits of decision analysis but the purpose of his version of medical decision analysis was to bring about a utilitarian outcome, namely the greatest medical outcome for the greatest number. Eddy admitted that there would be winners and losers in such an approach and implied that the group benefits trumped any individual loss or losses.

Dr. Robert Berenson  carried forward the plea for Platonic medicine  in the Annals of Internal Medicine  in 1998  in which he proposes that physicians should be devoted to  the health of the collective rather than the individual patient.

"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible."

Berenson recommends a replacement of the fiduciary duty of the physician to the patient with a duty to a group .This represents a sea change in medical ethics.

Outside of the HMO setting (or now the ACO) to what group would a physician owe his allegiance ?(Would a retainer physician strive to maximize the health of the city or states in which he practices or the country or what? Berenson's ethical proposal seemed to be aimed  primarily at HMO physicians as in the late 1990s the role of physicians in HMO settings was of concern and the topic for much discussion.


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